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HomeMy WebLinkAboutELEVATOR INSPECTION REPORT,� yo(oiA55 INSPECTION DATE TYPE OF INSPECTION & W 2"E l y,;.a- _ 1 •Ins Inspection (J P jfl 2-Initial t' o' 0 '0 :6, (uz! 0 4 - Construction 3 - Callback [] 6 -Alteration -z 13, . ;zl 'z '3t t � i 'ns, . 'DBPR USE ONLY. 91 4j rob U 5 - Complaint Q 8 -TOP (Temporary [51 s) 8rl Operating Permit) 6' t61 ;J (D 7 - Monitoring 0 9 -Accident �l n (9" '91 Building Name Building Address , I- ----TOR ;01 iol !(0 lo`I 1 r 'i 2: 12! �2i 2 3i3. 13l !3' 4 4i 4, `4. 5 -51 L -LSj Is) 16) jsj 7 -7; `71 71 S Iel e; (8j A - MAJOR VIOLATIONS 6-MINOR VIOLATIONS d d b C) rot (ol ll U UC? I>1n z; l,zl [] ?l r3l (3( i3j (3i ( 15� 9 E5) I6f (6j (_j it- n 07 [7] B) Bj 08 r) 0 L7 i_7 State of Florida DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION Division of Hotels and Restaurants' Bureau of Elevator Safety Northwood Centre, 1940 North Monroe Street, Tallahassee, FL 32399-1013 Phone:850-488-9097 www.hospitalityeducation.org Fax: 850-922-6208 EL NOTICE TO ELEVATOR OWNER Successfully passing an initial inspection authorizes use of a copy of this form as a temporary certificate of operation until receipt of the original certificate of operation issued by the Department of Business and Professional Regulation or for a maximum of sixty (60) days, whichever occurs first. REPORT NUMBER DEFINITIONS QEI — Qualified Elevator Inspector COI} Certificate of Competency NOTICE TO CERTIFIED ELEVATOR INSPECTOR Completed inspection report must be returned to the Bureau of Elevator Safety within five (5) working days of,inspection. PERSON RECEIVING THIS REPORT Print Namee�— Title -4 O 14 'l 11 ri I� 1 s.� \ � C, a C- t - Signa}ure- Phone Number .�--.-__'a" ...SEE REVERSE SIDE FOR DEFINITIONS OF VIOLATIONS HOISTWAYIN PIT J W4111, W' 1 �•• i AMOUNT COLLECTED SERIAL NUMBER !i 7 ri ig 0 U 0 0 nnnnn oono.n o[3)P 0 ®oonF� ®015)00 O 0 n 0 0 n o ©. 0 ��0�8 09 0 rrr�6�n1 09 SUPERVISOR OF CONSTRUCTION I ceniyy that as me elevator company supervisor, I directly supervised we construction or installation o/ ifliis e!evaton Signature �.�..✓ _ ry. ` Pant Name•i Phone I- �7rU., ♦ '%.5 QEI# coca Orsee attached elevator insWlalion affidavit.. Q ELEVATOR INSPECTOR CALLBACK I ceniy the violations cited on the previous inspection re on have been corrected. Signature Print Name Phone QEI# © ELEVATOR INSPECTOR C. I certify that I have personally perform¢d or witnessed CI Routine inspection Periodic tests as prescribe ll� by ASME A17.1 ® Acce lance Inspection of ne'w or altered �> ASMEahon as A172 InspectcsnMaqua the Signature Print Name 1 Phone 7 1K 7 QEI# c Z © Installation meets or exceeds minimum standards of 'chapter 399. Florida Slatutes, and Chapter 30 of the v)t+rFlorida Building Code adopted by Rule 9133.047, Florida Administrative Code.