Form Ucc-22 - Application For Alteration Permit - Lifting Devices Page 3
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1
2
3File #:
____________________
Permit #s:
____________________
____________________
____________________
____________________
ELPA
Part L:
If a building plan review and approval was required to complete any of the work listed on this
Building
application, lifting device approval cannot be granted unless the following information is supplied
(regarding building approval) and certified by a licensed design professional (architect or engineer).
Approval
Building Name
______________________________________________
Address
______________________________________________
______________________________________________
______________________________________________
If approval granted by Department of Labor & Industry :
Drawing Index/UCC Permit Number: ____________________
File Number: ____________________
Date of Approval: ____________________
Code Approved Under: _____________________________________________
If approval granted by a municipality (or a third party agency on behalf of municipality):
Name of Municipality:
Type (check one):
Borough
City
Township
Permit Number: ____________________
Date of Approval: ____________________
Code Approved under: _____________________________________________
Name of Building Code Official: _____________________________________________
Phone Number: ______ - ______ - ____________
I hereby certify that the building named above in which this lifting equipment will be located is
designed to meet all fire safety, structural and other building code requirements applicable to the
lifting devices to be installed in this building.
Name of design professional: _____________________________________________
Signature of design professional: _____________________________________________
Seal of design professional:
SEAL
Applicant
By signing this document, I certify that the proposed work will comply with the Pennsylvania Construction
Code Law (1999, November 10, P.L. 491, No. 45), its regulations and all applicable standards.
Signature
Name (printed): _____________________________________________
Name (signed): _____________________________________________
Date:
_______________________
FOR
Approved by:
________________________________
Date: ______________________
L&I USE
Applicable standards:
________________________________________________________
ONLY
UCC-22 REV 9-08 (Page 3)
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