Denver Fire Department
Fire Prevention Division
PO Box 40385
Denver, CO 80204
p: 720.913.3474
f: 720.913.3596
www.denvergov.org/fire
MICHAEL B. HANCOCK
Mayor
Facility/ General
Information
Electric Traction Elevator Safety Test Report
Building Name:
Manufacturer:
Capacity:
Address:
State Reg #:
Job/Contract#:
City:
Install Date:
Duty:
Zip:
Rated Speed:
Freight Loading Class: C1 C2
Circle One
Acceptance
Safeties
Governor /
Safety
Date Tests Performed:
Yes
Pass
Fail
Speed at which Governor Tripped:
Slack Rope Device (winding drum machines):
Governor Rope Pull Through Force:
NA Pass Fail
Car Safety, No Load, Slow Speed:
Pass
Stop Switches:
A
B
Fail
Yes
If "Yes" Inspector Must Sign Test Report
Pass
CW Safety, No Load, Slow Speed:
Pass
Fail
No
Pass
Fail
NA Pass
Emergency Limits: Up:
NA
Fail
Pass
Fail
Fail
Pass
Top of Car:
Directional & Final Limits: Up: Pass Fail
Broken Rope, Tape or Chain Switch Tested:
No
No
in
in
Test Tag Installed:
Stop Switch in Machine Room, Machine Space or Control Space:
Down: Pass
NA Pass
Braking System (125% Rated Load):
Pit:
Yes
Yes
Car Slide Of Safety Jaws On Rail:
CW Slide Of Safety Jaws On Rail:
Type C Safety Buffer Oil Loss: Yes No
In Car:
Fail
fpm
Governor Tripping Speed Setting in Need of Adjustment:
Governor Adjustments Sealed:
Pass Fail
NA Pass Fail
C
C3
Governor Overspeed Switch Tripping Speed:
lbf
Elevator out of Level after Safety Test:
No
Governor Tripping Speed:
fpm
Car Safety, Full Load, Rated Speed:
CW Safety, No Load, Rated Speed:
Freight
Category 5 Tests and Witnessed
Was Inspector Present:
Mechanical and Visual Check of Governor Operation:
Type of Safety:
Safety Devices
Category 1 Tests
Passenger
Pass
Fail
Fail
Down: Pass
Traction-Loss Detection Means:
Ascending Car Overspeed Protection and Unintended Car Movement (no load / up direction):
Broken Suspension Member & Residual Strength Detection Means:
NA
Pass
No
Fail
Escape Hatch Contact:
Pass
Fail
Yes
NA Pass Fail
Fail
NA
Pass
Fail
NA
Pass
Fail
Fail
E/E/PES Electrical Protective Devices Operate as intended: NA Pass Fail
E/E/PES Written Procedure Provided:
NA Yes No
The person or firm maintaining the equipment shall provide a written checkout procedure and demonstrate that all E/E/PES electrical protective
devices operate as intended.
Buffers
Type:
Spring
Solid
Oil
No
Pass
Fail
Excessive Buffer Oil Leakage:
Yes
No
CWT Buffer No Load, Rated Speed:
Pass
Fail
Car Oil Buffer Return (90 sec):
Pass
Fail
Test Tags Installed:
Yes
No
Door Guides Secure:
Yes
No
Power
Doors
Down
Closing Force (Max 30lbf):
Emergency
Operation
Phase I Recall:
Logs
Yes
Car Buffer Rated Load, Rated Speed:
CW Buffer Return (90 sec):
Signatures
Buffer Data Plate in Place:
Closing Time:
Proper Fuses Installed:
Controller Clean:
Pass
Fail
lbf
sec
Electronic Edge:
Yes
Yes
Buffer Switch:
Safety Edge:
No
No
Jumpers Removed:
NA Pass Fail
NA
Pass
NA
Pass
Yes
Relay(s) Visually Inspected:
Fail
Fail
No
Yes
Door Interlocks/Gate Switch:
Pass Fail
Wire Connections Tight:
Yes
No
No
NA
Pass
Fail
Phase I Fire Service Instruction Signage In Place:
Yes
No
Phase II Operation:
NA
Emergency Communication: NA
Pass
Pass
Fail
Fail
Phase II Fire Service Instruction Signage In Place:
Alarm Bell:
Pass Fail
Emergency Lights:
Yes
Pass
No
Fail
Standby or Emergency Power Operation:
Logs Properly Maintained:
Yes
No
Note: 125% of rated load not required
NA Pass Fail
Logs Updated with this Annual safety test:
Yes
No
Fire service logs maintained:
Yes No
I certify all statements are true to the best of my knowledge and that all testing was performed according to The Elevator and Escalator Certification
Act CRS § 9-5.5, Conveyance Regulations 7 CCR 1101-8 and adopted Codes.
Mechanic Name:
Company Name:
Signature:
Date:
Inspector Name:
Company Name:
Signature:
Date:
StateLicense #:
State License #:
6/24/13