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Minnesota Department of Labor and Industry Reset

Construction Codes and Licensing Division


Elevator Inspections
443 Lafayette Road North
St. Paul, MN 55155-4341
Phone: (651) 284-5071 Fax: (651) 284-5749 Elevator Witness Load Test
www.dli.mn.gov
PRINT IN INK or TYPE your responses.

Annual 5-Year Acceptance Alteration

Complete all items at time of acceptance, alteration, or 5-year tests. Complete asterisk (*) items for annual inspection.
Write N/A if not applicable.
TYPE OF MACHINE MANUFACTURER

OWNERS DESIGNATION FREIGHT PASSENGER


WHEELCHAIR SPECIAL
STATE IDENTIFICATION NO. SERIAL NO.

Rated load (lbs.) Rated speed ft/min. No. of openings No. of landings Installation code year Alteration code year

OWNER NAME ELEVATOR LOCATION

OWNER ADDRESS ELEVATOR ADDRESS

CITY STATE ZIP CODE CITY STATE ZIP CODE

PROVIDE THE FOLLOWING INFORMATION

*Do the safe edge and lights rays, or electronic door reopening device function properly? Yes No

*Do all interlocks function properly? Yes No

*Does car stop level at all floors? (1/2 in. above/below allowable) Yes No

*Phase I fire service operational? Yes No

*Phase II fire service operational? Yes No


*Door closing force measures (lbf) Front __________ Rear __________

*Do door restrictors work properly? Yes No

*Does 2-way communication work properly? Yes No

*Emergency lighting and alarm bell operation tested? Yes No

HYDRAULIC SECTION

Car speed loaded: ft/min Up __________ Down __________ Car speed unloaded: ft/min Up __________ Down __________

Loaded working pressure at pump: *Unloaded working pressure at pump: *Relief valve pressure:

PSI _______________ PSI ________________ PSI ______________

*Relief valve sealed? Yes No *Did the elevator engage the stop ring during test? Yes No

*Does the car leak down? Yes No *Amount of movement after 15 minutes __________

*Visible leaks in pit? Yes No *Level of oil in tank: __________ inches

*Piston diameter __________inches *Condition of packing: OK Replace

Condition of hydraulic hose and fittings OK Replace NA Next replacement date of hydraulic hose: ____________________

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or
TDD (651) 297-4198.

EL012 (8//09) (over)


TRACTION SECTION

Car speed loaded: ft/min Up __________ Down __________ Tripping speed: FPM Car __________ Cwt. __________

*Type of governor: ________________________________________________________________________________________

Governor pull through force __________ Car safety pull out force __________ *Governor/s sealed: Yes No

Governor ropes: Manila Iron Steel


Condition of governor rope prior to test: Condition of governor rope after test:
Car OK NG Cwt. OK NG Car OK NG Cwt. OK NG
Governor sealed by whom: ____________________ Date sealed __________ Governor safety test tags applied: Yes No

*Condition of safeties PRIOR to test: Car OK NG Cwt. OK NG


*Type of safety: Car _______ Cwt. _______ **Length of safety rope pull out: Ft. _____ In. _____ **Turns left on drum: _______

*Car safeties tested with _____ pounds load at _____ FPM *Cwt. safeties tests with ______ pounds loads at _____ FPM

Car safety jaw railing marking: Ft. _____ In. _____ Cwt. safety jaw railing marking: Ft. _____ In. _____

*Did car set level (3/8 inch per foot DBF allowable)? Yes No *Did Type C plank set level (1/2 inch allowable)? Yes No

*Condition of hoisting cables: OK NG Rope data tag installed: Yes No


Reshackle date: ________________________________________ Bottom runby: Cwt. _____________________________________

*Does car safety switch work properly? Yes No NA *Cwt. safety test tag applied? Yes No

*Does slack cable switch work properly? Yes No NA *Cwt. safety test tag applied? Yes No

*Condition of safeties AFTER test: Car OK NG Cwt. OK NG

*Type of Car buffers: Oil Spring *Type of Cwt. buffers: Oil Spring

Were Car and Cwt. run onto buffers? Yes No Oil plunger return within 90 seconds? Yes No
Buffer test tag applied: Car __________ Cwt. __________ Brake tested at 125% of rated load? Yes No

Ascending care overspeed protection tested? Yes No Unintended motion protection Tested? Yes No

REMARKS AND REPAIRS MADE

Companies certifies that this test was performed to the requirements of ASME A17.1 or A18.1

COMPANY PERFORMING TEST

MECHANIC PERFORMING TEST DATE

TEST WITNESSED BY INSPECTOR DATE