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) 284-5068 Fax: (651) 284-5749 Elevator Witness Load Test
www.doli.state.mn.us TTY: (651) 297-4198
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

OWNER’S DESIGNATION FREIGHT PASSENGER

WHEELCHAIR SPECIAL APPLICATION?
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

Loaded working *Unloaded working *Relief valve

Car speed loaded: ft/min *Car speed unloaded: ft/min pressure at pump: psi pressure at pump: psi pressure: psi
Up Down Up Down
Condition of hydraulic hose & fittings Next replacement date of hydraulic hose: *Relief valve sealed? *Does car leak down?
Yes No Yes No
*Condition of packing: *Condition of piston: If leaking, why?

Tripping speed-fpm: Over-speed switch tripping speed fpm Governor ropes: *Governor sealed:

Car Cwt. Car Cwt. Manila Iron Steel Car Yes No Cwt. Yes No
Governor rope slide through jaws of governor? Governor sealed by whom: Date sealed

Car Cwt.
Condition of governor rope prior to test: Condition of governor rope after test: Governor safety test tags applied? Rise
Car Cwt. Car Cwt. Car Cwt. Ft. In.
*Condition of oil: *Condition of hoisting cables: Rope data tag installed: Reshackle Date Bottom runby: Cwt.
Yes No
*Type of governor Cwt. safety jaw railing marking: *Do all interlocks function properly? Yes No
Car Cwt. Ft. In. *Does car stop level at all floors? (1/2 in. above/below allowable) Yes No
*Do the safe edge and lights rays, or electronic door reopening device function properly? Yes No
*Door closing force measures (lbf.) *Length of safety rope pull out: *Turns left on drum:

Front Rear Ft. In.

*Does slack cable switch work properly? Yes No *Does car safety switch work properly? Yes No
*Car safety test tag applied? Yes No *Cwt. safety test tag applied? Yes No
*Type of safety: *Condition of safeties prior to test: *Condition of safeties after test:
Car Cwt. Car Cwt. Car Cwt.
*Car safeties tested with pounds load at FPM *Cwt. safeties tests with pounds load at FPM
Car safety jaw railing marking: *Did car set level (3/8 inch per foot DBF allowable)?
Ft. In. *Did Type C plank set level (1/2 inch allowable)?

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 (6//07) (over)

 Were car & Cwt. run Oil plunger return within 90
*Type of car buffers: *Type of Cwt. buffers: onto buffers? seconds? Buffer test tag applied?
Oil Spring Oil Spring Yes No Yes No Car Cwt.
Brake tested at 125% of rated load? Yes No Phase I fire service operational? Yes No
Phase II fire service operational? Yes No Ascending care overspeed protection tested? Yes No
*Does 2-way communication work properly? Yes No *Do door restrictors work properly? Yes No
*Emergency lighting and alarm bell operation 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