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OFFICIAL USE ONLY PERMIT NO.: CITY ELEVATOR NO.: PERMIT FEE: This application & accompanying documents, which form a part of this application have been reviewed & approved Approved By: Title: Date: ELEVATOR PERMIT APPLICATION A SEPARATE PERMIT FOR EACH ELEVATOR IS REQUIRED & ELEVATOR LAYOUTS ARE REQUIRED TO BE SUBMITTED WITH PERMIT APPLICATION Building Address: Building Name: Contractor Information Elevator Contractor: Address: (please include zip) Phone: ( ) E-Mail: Owner Information Owner: Address: (please include zip) Phone: ( ) DESCRIPTION OF WORK: MODERNIZATION NEW CONSTRUCTION DRILLING ONLY TYPE OF ELEVATOR: ELECTRIC HYDRO OTHER USE CLASSIFICATION: PASSENGER FREIGHT OTHER ESTIMATED COST: NUMBER OF STOPS: NUMBER OF OPENINGS: All work must be done according to NYS Uniform Fire Prevention & Building Code and applicable ANI Upon completion work must be inspected by a licensed inspection agency – list is furnished with permit NO DEVIATION FROM THE APPROVED PLANS, SPECIFICATIONS, OR FROM THE SPECIAL CONDITIONS SET FORTH ABOVE MAY TAKE PLACE UNLESS REVIEWED BY THE DEPARTMENT OF BUILDINGS & REGULATORY COMPLIANCE AND APPROVED PRIOR TO IMPLEMENTATION. UNAUTHORIZED DEVIATIONS FROM APPROVED DRAWINGS, SPECIFICATIONS OR CONDITIONS WILL RESULT IN REVOCATION OF THIS PERMIT ELEVATORS ARE NOT TO BE PUT INTO SERVICE UNTIL A CERTIFICATE OF COMPLIANCE/OPERATION IS OBTAINED FROM THE DEPARTMENT OF BUILDINGS & REGULATORY COMPLIANCE AND POSTED IN THE ELEVATOR MACHINE ROOM. DECLARATION I hereby make application for a permit to carry out the work described above and in the accompanying documents. I hereby agree to complete all work in compliance with all applicable laws, ordinances and regulations. I declare all statements made in this application are true to the best of my knowledge. Signature of Applicant: Date: