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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