Roped & Hydraulic Elevator Annual Safety Test Report
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1Periodic Hydraulic Elevator Tests
Elevator License #
Submitted Date
Elevator Contractor License #
Building Name
Building Contact
Construction Code Services
th
250 South 4
Street, Rm. 300
Address
City
Minneapolis, MN 55415
Phone: 612-673-3000
Fax: 612-673-5974
TEST TYPE
8.10.3 ACCEPTANCE
8.6.5.14 CATEGORY 1
8.6.5.16 CATEGORY 5
UNIT TYPE
Passenger
Freight
Roped
Other:
Frequency
Description
Result
Mech. Initial
Date
A
5
1
Acceptance – 5yrs – 1yr
X
X
No Load pressure
NL
X
Full Load
FL
X
Calculated Load factors - Piston Diameter
Capacity
Calc. FL
X
X
Relief Valve Pressure
PR
X
X
Cylinder and piping – Leak Test - Movement 15 Min.
P
F
N/A
X
X
Normal & Final terminal stopping devices: Examine and test for operation.
P
F
N/A
X
X
Oil Buffers
P
F
N/A
X
X
Firefighters’ Emergency Operation
P
F
N/A
X
X
Standby EP operation – annual; Battery Lowering - acceptance
P
F
N/A
X
X
ETSLD and ETSD test
P
F
N/A
X
X
Low oil protection – test for proper operation
P
F
N/A
X
X
SIL and EPD Devices
P
F
N/A
X
X
Flexible Hose and Fitting Assemblies
P
F
N/A
X
X
Pressure Switch
P
F
N/A
X
X
Door code zone
speed
and Door Closing force
P
F
N/A
X
X
Slack rope device. Test for operation.
P
F
N/A
X
X
Governors: operate manually – visual inspection verify parts operate freely
P
F
N/A
X
X
X
Gov. Trip Speed
Gov. Pull Through force
Safety Pull out force
N/A
X
X
X
Safeties:
P
F
N/A
X
X
X
Car Slide
Counterweight Slide
N/A
X
X
X
Coated Rope Inspection
P
F
N/A
X
X
X
Wire Rope Fastening Inspection (Roped Hydro)
P
F
N/A
X
X
X
Plunger gripper examine and test
P
F
N/A
X
X
X
Over-speed Valve
P
F
N/A
X
X
X
Class C2 Freight Elevators *See Clarification Notes
P
F
N/A
COMMON VIOLATIONS
8.6.1.2.1(d)
Access provided for Inspector and Mechanic for MCP and Records?
Y
N
8.6.1.7.2
Test tag securely attached to controller?
Y
N
8.9.1
Code Data Tags present and up to date
Y
N
8.11.3.1.1(e)
Car lighting – Test back up with power off (not test button)
P
F
N/A
8.11.3.1.1(f)
Emergency Com. Phone\Alarm Bell– tested with normal power off
P
F
N/A
8.11.3.1.1(r)
Restriction of door open: = or < than 4” outside of the unlocking zone.
P
F
N/A
This form is designed to allow the user to identify when a required test was completed within the identified timeline, and the licensed
individual (mechanic) performing the test. Category tests are to be completed as identified. Complete the form, and submit a copy annually
to the City of Minneapolis. Any results identified as “Failed” shall be addressed immediately with the owner. Licensed elevator contractors
shall not leave any elevator in service if an unsafe condition exists as a result of these or any other tests.
Tests were performed in compliance with A17.1 using A17.2 as a guide.
Master Name and License #:
SIGNATURE
Date:
Acceptance tests Signed by Inspector
SIGNATURE
Date:
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