Parts of this form maybe filled out before printing.
Request Schedule an Elevator Field Inspection
State ID# ____________________ Permit #________________ Request Date(s) of Inspection: ______________________________
Location: ____________________________________________ Address: _________________________________________________
City: ________________________________________Zip: ___________________ County: __________________________________
INSTRUCTIONS:
Fax this form to 614.644.3580 to schedule a new or alteration inspection. ALLOW 48 HOURS FOR A RESPONSE to your request.
Cancelled inspection and re-inspection will be scheduled based upon availability of field inspectors. To obtain a re-inspection, submit this
same form which is available at
Company Making the Request: ___________________________________ Contact Person(s): ______________________________
Contact Phone #__________________________ Conformation Fax #___________________________
Type of Inspection:
New
Alteration
Reinspection
Other (specify) _____________________
DIC4330
Numbers of Floors _______
NOTE: To ensure proper scheduling for an alteration, please describe all items that have been altered.
Directions to the elevator location site: (include known crossroads)
List known violations if your intention is to apply for a temporary certificate of operation.
List any other site specific notes that maybe needed.
Signature: ______________________________
Print Name:___________________________
(will not be scheduled without a signature)
Please read before signing: My signature acknowledges that the elevator has been reviewed for violations prior to requesting an
inspection against the common violations checklist included with the installation permit. It is acknowledged that a State of Ohio
inspector must insect an elevator before a certificate of operation of operation can be issued as outlined in ORC 4105. No person or
company, including a contractor, owner, tenant or elevator installer may use the elevator to haul materials, furniture or persons not
directly related to the construction of the elevator until a certificate is issued. Elevator companies may not operate the elevator as a
The elevator
material lift unless a certificate of operation has been issued by the State of Ohio after an inspection has been performed.
inspection section does not perform “punch-list” type inspections or provide consulting service.
The area below is for State of Ohio Office Usage:
Date of Inspection: ____________________________Time: _______________________________ Inspector: _________________
Notes:
DIC4329 revised 2-14-2007