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OFFICIAL USE ONLY PERMIT NO.: CITY ELEVATOR NO.: PERMIT FEE: 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: