Form Ucc-22 - Application For Alteration Permit - Lifting Devices

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File #:
____________________
Permit #s:
____________________
____________________
____________________
____________________
ELPA
Uniform Construction Code (UCC)
APPLICATION FOR ALTERATION PERMIT: LIFTING DEVICES
All of the information on this form must be supplied before a permit will be issued for the alteration and major repair of any
elevator, escalator, moving walk or wheelchair lift. (It may not be used for replacement of an existing elevator.) This application
may be for the alteration/repair of as many as four identical lifting devices, as long as all of the equipment is within the same
hoistway and machinery space.
Part A:
Building Code (MD) Number:
_____________________
Certificate of
Responsible Party Number:
_____________________
Operation
State-Assigned Equipment Numbers:
________ ________
________
________
Numbers
Part B:
Owner Name
______________________________________________
Owner
Street Address
______________________________________________
Information
City
____________________
State __________
Zip Code __________
Phone Number
(_____)
_____ - ____________
Part C:
Building Name
______________________________________________
Building
Street Name and #
______________________________________________
Information
City
____________________
State __________
Zip Code __________
Political Subdivision
_______________________
County ______________________
Use/occupancy of this building:
_____________________________________________
Does building have a basement:
Yes
No
Number of stories: ________
Part D:
Passenger
Passenger/Freight
Freight with class loading:
A or
B or
Elevator
C: 1 2
3
Dumbwaiter
LULA
VRC
Other (specify):________________________________
Type(s)
Part E:
Geared
Gearless
Hydraulic
Equipment
Roped-Hydraulic
Other (specify):________________________________
Type(s)
Original
New
Original
New
Part F:
Equipment
1.
Capacity
_______ _______
Net Inside Platform Area _______ _______
2.
Car Speed (Up)
_______ _______
Car Speed (Down) _______ _______
Data
3.
Travel
_______ _______
No. of Stops _______ _______
4.
No. of Openings
_______ _______
Platform Size _______ _______
5.
Gross Weight
_______ _______
6.
Floor Designations
______________________________________________
Note: If a new cab or cab interior is to be provided, you must state both the original and new data.
If the capacity, overall car weight or the speed is increased, and if this lift requires a safety,
provide the following for this safety:
Make: _________________ Model: _______________ State Certificate No.: _______________
FOR
L&I USE
Check Number:
_____________
Amount:
_____________
Bates Number:
_____________
ONLY
UCC-22
REV 9-08 (Page 1)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR & INDUSTRY (BOIS-ELEVATOR DIVISION)

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