Installers Declaration Of Completion(Initial Or Alteration) Form

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INSTALLERS DECLARATION OF
COMPLETION (Initial or Alteration)
Community Services
DÉCLARATION SUIVANT L’INSTALLATION
Services aux collectivités
INITIALE OU LA MODIFICATION
Please print all information
For Devices covered by the CSA B-355, B-311, Z-98, Z-267, Z-185 Codes
Veuillez écrire en lettre détachées
Handicap Lifts, Manlifts, Passenger Ropeways, Amusement Rides,
Personnel Hoists
Appareils régis par les codes de sécurité CSA B-355, B-311, Z-98, Z-267,
Z-185 (appareils élévateurs pour personnes handicapées, monte-personne,
Yukon I.D. #
remontées mécaniques, jeux et manèges, monte-charge provisoires)
Numéro d’identification du Yukon ____________________
Building Name:
Nom du bâtiment : _________________________________________________________________________________
Site Address:
Adresse du site : __________________________________________________________________________________
Elevator Contractor:
Entrepreneur qui effectue l’installation (ou la modification) : _________________________________________________
Phone Number:
Téléphone : _________________________________________________
Note: This document must be completed and received by the Elevator Inspector prior to the initial inspection.
Nota : Le présent formulaire doit être rempli et remis à l’inspecteur des ascenseurs avant l’inspection initiale.
1.
This elevating device has been installed according to the registered design/drawings.
Cet appareil élévateur a été installé en conformité avec les plans déposés.
2.
The installation of the device meets all the requirements of the applicable codes and regulations.
Cet appareil élévateur est conforme aux codes de sécurité, lois et règlements pertinents.
3.
All directives issued as a result of the design/drawing registration have been complied with.
Les directives données à la suite du dépôt des plans ont été suivies.
Please note exceptions to the above:
Exceptions à ce qui précède, s’il y a lieu :
1.
____________________________________________________________________________________________
2.
____________________________________________________________________________________________
3.
____________________________________________________________________________________________
4.
____________________________________________________________________________________________
5.
____________________________________________________________________________________________
Note: Attach more information if required.
Nota : Veuillez joindre en annexe tout renseignement supplémentaire, au besoin.
I, _________________________________________ declare that the information in this declaration to be true and this
device is ready for initial inspection.
Je soussigné(e), ____________________________ , déclare que les renseignements contenus dans la présente sont
exacts et que l’appareil est prêt pour l’inspection initiale.
Date:
Certificate No.
Date : ________________________________
Certificat n
_________________________________
o
Signature:
Position/Title:
Signature : __________________________________ Poste/titre : _________________________________
Nota : Dans le présent document, les expressions désignant des personnes visent à la fois les hommes et les femmes.
YG(5407Q)F1 04/20
11
Print/Imprimer
Clear/Vider les champs

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