Safety & Buildings Division - Wisconsin



| |APPLICATION FOR REVIEW |Division of Industry Services |

| |ELEVATORS, ESCALATORS |4822 Madison Yards Way |

| |AND RELATED CONVEYANCES |PO Box 7302 |

| |-Complete both sides- |Madison WI 53707-7302 |

| | |Contact Through Relay |

| | | |

|Please type or print clearly. Information on this form is important for providing timely and efficient review of your project. |

|Complete submittals prevent delays in processing and reviewing of your project. |

|Except for Emergency Repairs, work may not commence until approved. |

|Scheduling Review: Your plan will be reviewed in the order it was received or you may schedule the review. To schedule, fax completed form to (877) 840-9172 or |

|e-mail to DSPSSbPlanSchedule@. You will receive a confirmation letter with an appointment date. Plans must be received in this office no later than 2 |

|working days before the confirmed appointment. |

|Use (check one) | |2. Type of Submittal: |Building Plan Rev. Trans ID:       |

|Commercial Bldg./ Shared |Single Residential Dwelling |New Installation |Previous Related Petition for Variance Transaction ID|

|Elevator |Elevator |Complete replacement of existing |Number (where applicable).       |

|Passenger Elevator |Residential Elevator |elevator,lift,escalator,etc |For office use only |

|Freight Elev. (circle class) |Residential Inclined El. |Alteration or Repair |Transaction ID:       |

|A B C1 C2 C3 |Passenger Elevator |Emergency Repair |Assigned Review Date:       |

|Inclined Elevator |Freight Elev. (circle) A B C1 |State Tag or Regulated Object No.|Assigned Reviewer:       |

|Limited Use (LULA) Elev. |C2 C3 |of existing unit:       |Assigned Office:       |

|Power Sidewalk Elevator |Inclined Elevator |(See box 7, page 2) | |

|Special Purpose Pers. Elev |Limited Use (LULA) El. | | |

|Part V Elev. (remod only) | | | |

|Stage/Orch. Elevator |Dumbwaiter | | |

|Dumbwaiter / Material Lift |Dumbwaiter | | |

|Dumbwaiter |Note: Plan review and inspection | | |

|Type B Material Lift |of elevators and dumbwaiters in | | |

|Moving Stair / Walk |private residences is required for| | |

|Escalator |contract dates on or after January| | |

|Moving Walk |1, 2009. This is based on the | | |

|Lift |date of contract between elevator | | |

|Vertical Platform Lift |installer and home owner, builder | | |

|Inclined Platform Lift |or developer. | | |

|Stairway Chair Lift | | | |

| | |3. Project Site Information |

| | |Project Name:       |

| | |Project Address:       |

| | |City Village Town of:       |

| | |County:       |

| | |Elevator Number, tenant name and / |

| | |or building designation       |

| | |4. After plans are reviewed, please: (check all that apply) |

| | |Requesting party will pick up. |

| | |Mail plans to customer 1, 2, 3, 4 (circle number here) |

| | |Plans to be E-filed (enter SharePoint ID below in Customer 1) |

|Date of Contract | | |

|(between elevator | | |

|contr. and owner)       | | |

|5. Complete the following installer and owner information. |

|Elevator Installer / Contractor Information (Customer 1) |Requesting Party if different than Installer (Customer 3) |

|First Name |Last Name |Customer Number       |First Name |Last Name |Customer Number       |

| |      | |      Last Name |      | |

| | | |Customer Number | | |

|Company Name |Company Name |

|      |      |

|License Number (valid Contractor license number required) |Address |

|      |      |

|Address |City |State |Zip code |

|      |      |   |      |

|City |State |Zip code |Phone |Fax |E-mail address |

|      |   |      |      |      |      |

|Phone |Fax |E-mail address | |

|      |      |      | |

|SharePoint ID (for Electronic Plan Review) | |

|      | |

|Owner Information (Customer 2) |Other(Customer 4) |

|First Name |Last Name |Customer Number       |First Name |Last Name |Customer Number       |

|      |      | |      |      | |

|Company Name |Company Name |

|      |      |

|Address |Address |

|      |      |

|City |State |Zip code |City |State |Zip code |

|      |   |      |      |   |      |

|Phone |Fax |E-mail address |Phone |Fax |E-mail address |

|      |      |      |      |      |      |

|Check if applicable |Check if applicable |

|Payer |Payer Manufacturer Other |

|Personal information you provide may be used for secondary purposes [Privacy Law s. 15.04(1)(m)] |

6. General Equipment Information (Complete ALL applicable information)

| |Type of Drive Unit: | Rack and pinion |Rated Load (lbs):       |

|Number of Landings:     |Cable Ball & Socket |Roped hydraulic |Suspension Means: |

| |Chain (electric) |Screw |Elevator Wire Rope |

|Number of car or platform openings:     |Chained hydraulic |Traction – penthouse |Aircraft Cable |

| |Direct hydraulic |Traction – basement |Kevlar Rope |

|Note: Car or platform openings (doors/gates) are counted |Direct hydr - mach. room less |Traction – machine room less |Non-Circular Coated Steel |

|from inside the elevator, dumbwaiter or lift. Number of |Hand |Winding drum |Chain |

|car or platform openings does not usually equal the | | |Number of Susp. Means:      |

|number of landings and is rarely more than 2. | | |Size of Susp. Means:       |

|7. Replacement, Alteration or Emergency Repair Complete all information in Box 6 above and any items in Box 8 that are changing as part of this project. Describe |

|the scope of the project in this space. If more space is needed, attach a project specification or project description. |

|      |

|8. Specific Equipment Information (Complete ALL applicable information) |

|Hoistway / |Speed Up     |Speed Down      |Overhead Clear. |Pit Depth |Total Travel |Car Inside Dimension |

|Runway and Car |fpm |fpm |    ft.    in |   ft.    in |     ft.    in |      x       |

|/ Platform | | | | | | |

|Machine |Machine Type |Mach. Location |Primary Brake Type |Emerg. Brake Type |Sheave Size |Rope Const. |Hydraulic Control Valve |

| |      |      |      |      |      In. |      |Manuf.       Model no.       |

|Electrical |H. P. |Volts – main |Phase |On Emerg / Stand-by Power |Batt. Emerg. Lowering Only |Batt. powered - Up / Down |Volts - Battery (if |

| |0 |      |   |Yes No |Yes No |Yes No |battery powered)       |

|Safety / |Safety Type |Approved |Safety |Governor Type |Gov. |Slack Rope/ |2.19 device |

|Governor/ |A B |Cap. (lbs.)|Manufacturer       |Non Fly-ball |Manufacturer       |Chain Swtch |Manufacturer       |

|2.19 device |C |      | |Fly-ball | |Yes | |

| |other | | |Friction other | |no | |

| | | |Safety | |Gov. | |2.19 device |

| | | |Model No.       | |Model No.       | |Model No,       |

|Fire Serv. / |Fire Fighter’s Service |Location of Any Remote Fire |Designated |Alternate Evac.|Sprinklers |Machine/Control Room | Y N NA |

|Fire Safety |None Phase I |Recall Key Switches |Evac. Level |Level |in: |Top of Hoistway /Runway |Yes No |

| |Phases I & II |      |      |      | |Pit |Yes No |

9. Fees

|For Map showing State-inspected counties and |New installation or complete replacement of an existing conveyance |Alteration, repair or |

|Private-inspected counties, please see | |modernization of existing |

| | |

|aps/Conveyance%20Map.pdf | | |

| |In county with State Inspection |In county where Private Inspector |In county with|In county where |

| | |will bill for inspection |State |Private Inspector |

| | | |Inspection – |will bill for Insp.|

| | | |Total Fee |-Total Fee |

| |

| |

10. Applicant Signature: I certify all the above statements are true and accurate to the best of my knowledge and belief

| | | | | |

| | | | | |

Signature Title Date Signed

SBD-22 (R 6/2019)

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