Free f621-051-000 Elevator Five Year safety Test Report - Washington


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http://www.lni.wa.gov/Forms/pdf/621051af.pdf

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Department of Labor and Industries Elevator Section PO Box 44480 Olympia WA 98504-4480 Phone: (360) 902-6130 FAX (360) 902-6132
www.Lni.wa.gov/TradesLicensing/Elevators

ELEVATOR FIVE YEAR SAFETY TEST REPORT

Send originals to above address File a separate report for each car and counterweight tested. Car 1. Building name 2. Building Address 3. Elevator Conv # 4. Capacity 5. Governor Type 6. Condition of Governor 7. Governor Data Plate 8. Governor Rope Trip Speed Type Yes Yes Yes Bail Owner ID Speed Flyball Centrifugal Jaw Type Pull Through Size No No No Where located? Type of Machine Rail type Other Condition Pull Out Condition or Counterweight

9. Governor Rope Cable Tag attached? 10. Governor Overspeed Switch? 11. S.O.S Switch? 12. Governor Tension Frame condition 13. Releasing Carrier condition 14. Type of Safeties A B

C

15. Condition of Safeties & Actuating Rods 16. Buffer Type
17. Buffer Data Plate

Standard
Min Load

Reduced Stroke
Max Load

Other
Max speed

Car
Car

Cwt
Cwt

18. Buffer Switch 19. Run by Car

Yes

No

Buffer Oil Level Cwt Yes No (dimension in inches) Tags attached? Yes No Inches

20. Have all annual tests been completed?
F621-051-000 elevator five year safety test report 05-2006

21. Length of governor rope movement for safety jaws to touch rail

22. Clearance between the safety jaws and rail 23. Governor tripped at? 24. Overspeed switch trips at 25. Governor rope pull thru 26. Safeties tested with fpm Is the governor sealed? Yes

Inches No fpm lbs fpm Yes feet No inches

fpm Governor switch trips at lbs lbs at Releasing carrier pull out

27. Did the car stop level (3/8" per foot DBG maximum?) 28. Length of safety rope pull out 29. Number of turns remaining on drum 30. Safety jaw rail marks (average of 4 marks) 31. Oil buffer test: Car buffer with Counterweight buffer with no load 32. Did plunger return within 90 seconds? Yes No Yes Yes Yes No Yes Yes Yes

feet lbs at

inches fpm fpm

Car No No Car No No No

Cwt Bottom? Yes No

33. Were final limits actuated during the buffer test? 34. Did buffer switch actuate? Did buffers fully compress? 35. Was brake tested with 125% of rated load? 36. Did brake hold? 37. Are load weighting switches properly set? 38. Condition after test

Cwt

39. Have unsatisfactory conditions been corrected? If not, explain

40. Have all test tags been applied? Governor Yes No Releasing Carrier Date Signature

Yes

No

Buffers

Yes

No

Firm performing test

Phone

F621-051-000 elevator five year safety test report 05-2006

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