HomeMy WebLinkAbout1323 W Plum St - Special Inspections/Field Verification - 07/13/2018Colorado Department of Labor and Employment
Division of Oil and Public Safety – Conveyance Program
633 17th Street, Suite 500
Denver, CO 80202-3610
Phone: 303-318-8497
Fax: 303-318-8534
Email: cdle_conveyance@state.co.us
Web: www.colorado.gov/ops
Elevator Inspection Report – Private Third-Party Inspector
(Revised 8/12/2015)
To receive a Certificate of Operation, the Conveyance Responsible Party (owner/operator) must submit this Inspection Report,
along with the $30 processing fee (payable to the Division of Oil and Public Safety), to the Conveyance Program at the address
listed above.
Facility Information
Facility Name: Facility ID #: Phone #:
Facility Address: City: County: ZIP:
Responsible Party Information
Contact Name: Company Name:
Address: City: State: ZIP:
Phone #: Email Address:
Responsible Party Type: ☐ Owner ☐ Facility Management
Conveyance Information
OPS Conveyance #: CP- Job/Contract #:
Original Code Data Plate Year: Year Installed: Manufacturer:
Altered Code Data Plate Year: Year Altered: Conveyance Local ID #:
Conveyance Use: ☐ Passenger ☐ Service ☐ Freight Freight Class: ☐ A ☐ B ☐ C1 ☐ C2 ☐ C3
Conveyance
Type:
☐ Traction ☐ Roped-Hydraulic ☐ Vertical PL ☐ Dumbwaiter ☐ Home Elevator in Commercial Bldg.
☐ Hydraulic ☐ LULA ☐ Inclined PL ☐ Material Lift ☐ Other:
Front Landings: Rear Landings (if applicable): Rated Speed: fpm
Capacity: lbs Total Rise: ft Maintenance Contractor:
Inspection Information
Inspection Date: Start Time:
Inspection Type:
☐ Periodic
☐ Re-inspection
☐ Acceptance (notify OPS) ☐ Test Witnessed
Permit #:
☐ Category 1 ☐ Category 5
Type: ☐ Major ☐ Minor
Annual Safety Test Date: Witnessed Safety Test Date: Test tags in place? ☐ Yes ☐ No
Code Reference Violation Description
(Check if additional violations listed on next page: ☐)
Repeat
Violation2
TCO
Violation2
Date Corrected
Edition Year Reference (Inspector only)
A17.1
2013
8.6.1.2
Maintenance Control Program (MCP)
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1. General Requirements: ☐ Yes ☐ No
2. On-Site Documentation: ☐ Yes ☐ No
3. Maintenance Records: ☐ Yes ☐ No
Comments:
Elevator Inspection Report (Page 2)
Inspection Date: OPS Conveyance #: CP- Facility ID: Local ID:
Code Reference
Violation Description
Repeat
Violation
TCO
Violation
Date Corrected
Edition Year Reference (Inspector only)
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Colorado Division of Oil and Public Safety Elevator Inspection Report Form Page 2 of 2
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Inspection Result: ☐ Annual CO1 ☐ Temporary CO2 ☐ Construction CO ☐ Removed from service ☐ Dormant
1 All violations must be corrected prior to the next inspection.
2 TCO and repeat violations must be corrected within 90 days of the date of this inspection.
Certification Information
By signing below I certify that all statements made in this report are true to the best of my knowledge and that the inspection was
performed according to current regulations and adopted codes.
Inspector Name: Inspection Company Name:
Inspector Signature: Date: Phone #: State License #:
Colorado Division of Oil and Public Safety Elevator Inspection Report Form Page 1 of 2