Free TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT - Tennessee


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Date: October 17, 2008
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State: Tennessee
Category: Workers Compensation
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PLEASE NOTE: INCOMPLETE APPLICATIONS WLL NOT BE PROCESSED.

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT 220 FRENCH LANDING DRIVE NASHVILLE, TENNESSEE 37243-0655

PERMIT NO. ____________ TENN NO. ____________ ____________ DATE

STATE OF TENNESSEE APPLICATION FOR INSTALLATION OR ALTERATION OF ELEVATOR
INDICATE TYPE HERE: PASSENGER SELECT ONE: ALTERATION OR INSTALL FREIGHT D/W ESCALATOR WHEELCHAIR LIFT STAIRCLIMBER LULA CHAIRLIFT

OWNER NAME _____________________ ADDRESS ____________________ CITY ______________ STATE ________ ZIP _______________ OWNER PHONE NUMBER __________________________________ OWNER FAX NUMBER ________________________________________ LOCATION ADDRESS _________________________ CITY _____________STATE __________ ZIP _________COUNTY _________________ LOCATION PHONE NUMBER ________________________________ LOCATION FAX NUMBER ______________________________________ BILLING NAME ____________________ STREET _________________ CITY __________ STATE _______ ZIP ________ COUNTY _________ BILLING CONTACT PHONE NUMBER _______________ BILLING CONTACT FAX NUMBER _____________________ INSTALLER NAME ________________________________________ INSTALLER MANUFACTURER __________________________________ IF ALTERATIONS ITEMIZE IN DETAIL ON THE BACK ON WHAT YOU PROPOSE TO DO. ALL ALTERATIONS MUST HAVE A PREVIOUS ELEVATOR NUMBER INCLUDED BEFORE APPLICATION IS APPROVED SPECIFICATIONS SPEED___________NUMBER OF FLOORS_________CAPACITY_________________MODE OF POWER______________________________________

PREVIOUS ELEVATOR NUMBER ____________________
MACHINE LOCATION_____________ RISE: FT ___IN ___ NO. OPENINGS: __ LIGHT IN CAR: Y___ OR N___ INSIDE DIMENSION OF CAR: HT _____ PLATFORM SIZE:____ NUMBER OF CAR OPENINGS: ____ EMERGENCY EXIT: Y ___OR N ___ SIZE: __EMERGENCY STOP SWITCH: Y ___OR N ___ CAR: CONTROL TYPE_________(A.P.B, C.P.P. B. OR OTHER) HALL BUTTON: Y ___OR N ____ DOOR OR GATE TYPE, VERTICAL OR HORIZONTAL , HEIGHT_____ CLEARANCE BETWEEN CAR PLATFORM AND LANDING: ______________________ OVERHEAD CLEARANCE : CAR_____ CWT_____ PIT CLEARANCE: CAR___CWT____ NO OF HOIST CABLES: ___MATERIAL____DIAMETER: ____ROPING 1 TO 1___ 2TO 1____PIT DEPTH______ LIGHT IN PIT_________ LADDER IN PIT: YES ____ OR NO _____ EMERGENCY STOP SWITCH IN PIT: ________ CAR SAFETY TYPE: ____________ DIA OF SHEAVES HOIST: ____CAR: _____CWT: ____DEF: ____SECONDARY____ TYPE OF CAR BUFFERS: OIL OR SPRING STROKE:____________ CWT BUFFERS: TYPE: ____STROKE: _____CWT ________ GUARD____ HT_____ BUFFER CLEARANCE: _________ COMP CHAINS: Y ____ OR N ___ GOVERNOR: TYPE _______ DIA OF CABLE: _____ RAIL TYPE: _____ WGT PER FT: ________ CWT RAIL TYPE: _______WGT PER FT: ________ HOISTWAY DOORS OR GATES HOISTWAY VENTED: LOCATION _______SIZE: ____ FIRE RESISTANT ENCLOSURE: Y __ OR N __ HOISTWAY DOOR TYPE: BI-PART___ Y __OR N __ 2 SPEED: Y ___OR N ____ C `OPEN Y ____ OR N ____VERT S: Y ____OR N ____ OTHER: ___________ FIRE RATED MATERIAL: Y ____ OR N ____ TYPE OF OPERATION: MANUAL, POWER, OTHER___________ INTERLOCK MFG BY: ________ TYPE: _____ OPERATED BY: STA.CAM.____________ DOOR CAM: _________ RET CAM: ______________ IS ANY EMERGENCY DOOR RELEASE PROVIDED: Y ____OR N _____ TOP , BOTTOM OR ALL LANDINGS Y ____ OR N ___ EMERGENCY OP AND OR SIGNAL DEVICE: Y ____ OR N ____ TWO WAY COMMUNICATIONS: Y ___ OR N ___

ALL NEW INSTALLATIONS SHALL COMPLY WITH CURRENT A 17.1 CODE REQUIREMENTS
LB -0364 (Rev. 08-07)

_______________________________________________ Elevator Company _______________________________________________ Signature of Elevator Company or Contractor
RDA 2156

Fees for construction or alteration permit and acceptance inspection must be submitted with this application, as follows: (1) For construction permits for new or altered elevators, escalators and dumbwaiters required by TCA Section 53-2608(b) ......................................................................................... $150.00 (2) For acceptance inspections for new or altered elevators, escalators and dumbwaiters required by TCA Section 53-2606 (a) ........................................................................................ $150.00

ADDITIONAL INFORMATION: