Intent To Install Form - California Department Of Industrial Relations
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1STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
ELEVATOR, RIDE AND TRAMWAY UNIT
INTENT TO INSTALL FORM
Pursuant to Section 3001(a)(1) and Section 3001(a)(4) of California Code of Regulations, Elevator
Safety Orders, accept this letter as notice that __________________ Elevator Co., Phone
#: ____________ intends to install or alter an elevator(s) at the following location:
ADDRESS:
The following technical information is provided for your information:
Type of Unit: Pass; Frt.; DW; Esc; VRC; WCL; MW; Other. (Circle one or more)
Machine Type: _______ Rise: ______ Rated Speed: _____ Rated Load: _______
Control Type: ______________ Controller Model: ________________________
Medical Emergency Elevator (3041e) Yes_____
No ____
If no, attach documentation from Local Authority excusing requirement.
New Technology, Design or Observation Car: Yes or No (If yes, plans are attached)
Yes
New:
If yes, Number of Units: ______________
Yes
Alteration:
If yes, Number of Units: ______________
From Part XII or ASME A17.1 – 1996:
Rule#: _______________Description: _______________________________
Rule#: _______________Description: _______________________________
Rule#: _______________Description: _______________________________
Rule#: _______________Description: ______________________________
CA State ID Number(s):_________________________________________________
All necessary adjustments to the elevator will be completed before an acceptance
inspection is requested. The elevator will comply with all related Safety Orders in the
California Code of Regulations. Estimated completion date
/
/
.
Prepared by: _______________________________
Date: ___________________
Return Form To:
Division of Occupational Safety and Health
Elevator, Ride and Tramway Unit
GI/m(99)
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