Form Ucc-22 - Application For Alteration Permit - Lifting Devices Page 2
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1
2
3File #:
____________________
Permit #s:
____________________
____________________
____________________
____________________
ELPA
1.
Top Car Clearance: ____in. Top CWT Clearance: ____in. Bottom Car Clearance: ____in.
Part G:
Description
2.
Refuge Space:
Top: ____ inches
Bottom: _____ inches
3.
Bottom Car Runby:
_____ inches
Top Car Runby: _____ inches
of
4.
Lifting
Bottom Counterweight Runby:
_____ inches
Devices
5.
Number and Size of Hoist Cables/Chains:
___________
Safety Factor:___________
6.
Is hoistway door interlock certified/listed and labeled per §2.124.3?
Yes
No If
“no,” explain:__________________________________________________________
7.
Does this alteration also require a Building Permit approval
(per §8.6.3 or 8.7)?
Yes
No
NA
8.
Does the Building Permit include the lifting devices listed on
this permit application?
Yes
No
NA
9.
If you answered “Yes” to either of the preceding questions, you must supply the building
approval information requested in Section L.
10.
Line voltage:
_______ volts
Is it three-phased?
Yes
No
Part H:
Provide a complete description of the work covered by this application, citing the sections of the
Scope of
ASME standard applicable to the particular lifting device(s). Attach an additional sheet of paper to
Alterations
this application if required to describe fully the work you are proposing.
or
Code §§
Description of Alteration or Repair
Repairs
Do all the listed replacement components comply with §8.6.3.7?
Yes
No
Part I:
Building
Name
______________________________________________
Street Address
______________________________________________
Contractor
City
____________________
State __________
Zip Code __________
Phone Number
(_____)
_____ - ____________
Part J:
Elevator
Name
______________________________________________
Contractor
Street Address
______________________________________________
City
____________________
State __________
Zip Code __________
Phone Number
(_____)
_____ - ____________
Part K:
Contact Name
______________________________________________
Recipient
of
Company
______________________________________________
Approved
Street Address
______________________________________________
Application
City
____________________
State __________
Zip Code __________
Phone Number
(_____)
_____ - ____________
E-mail
________________________
UCC-22 REV 9-08 (Page 2)
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