Minnesota Department of Labor and Industry Reset

Construction Codes and Licensing Division

Elevator Inspections Residential Permit Application
443 Lafayette Road North Elevator Installation, Alteration or Removal
St. Paul, MN 55155-4341
Phone: (651) 284-5068 Fax: (651) 284-5749 (Submit Payment with Application)
www.doli.state.mn.us TTY: (651) 297-4198 (Two sets of plans and specs MUST be submitted)
PERMIT NO.
PRINT IN INK or TYPE your responses. MAKE CHECKS PAYABLE TO
All blanks must be filled out or application will be returned. DEPARTMENT OF LABOR AND INDUSTRY
SITE NAME OFFICE PHONE (Days) RES PHONE (Eves)

ADDRESS CITY STATE ZIP CODE

OWNER NAME OFFICE PHONE (Days) RES PHONE (Eves)

ADDRESS CITY STATE ZIP CODE

PRIMARY CONTRACTOR NAME CONTACT PHONE

ADDRESS CITY STATE ZIP CODE PCJOB #

ELEVATOR CONTRACTOR NAME CONTACT PHONE

ADDRESS CITY STATE ZIP CODE ECJOB #

EQUIPMENT
MANUFACTURER ORIGINAL DATE OF INSTALLATION

PASSENGER FREIGHT DUMBWAITER ESCALATOR HOIST

ACCESS LIFT INCLINED WHEELCHAIR LIFT VERTICLE WHEELCHAIR LIFT
HYDRAULIC TRACTION DRUM LIMITED USED RESTRICTED USE
INCLINED ELEVATOR STAIR CHAIR
RISE FEET RISE INCHES NET PLATFORM SIZE CAPACITY SPEED

UNIT CONTROL # LANDINGS # OPENINGS # HOISTWAYS

BLDG HEIGHT FEET BLDG HEIGHT INCHES # LEVELS CONSTRUCTION BLDG USE

IF ELEVATOR CONTRACTOR IS NOT A LICENSED ELECTRICAL CONTRACTOR, THE ELEVATOR CONTRACTOR IS RESPONSIBLE
FOR PROVIDING A COPY OF ELECTRICAL PERMIT WITH THIS APPLICATION.
ELECTRICAL PERMIT # (If not installed by MN Elevator/Electrical Contractor) MN ELECTRICAL CONTRACTOR NAME LICENSE #

TYPE OF ALTERATION; from A17.1, Section 8.7: Specify each type:

CONTRACT DATE DATE WORK TO COMMENCE

A. TOTAL COST OF CONTRACT $

B. INSPECTION FEE (.015 multiplier/$1,000 maximum) $

C. PERMIT FEE $100 OR
This material can be made available in different forms, LATE FEE $500 $
such as large print, Braille or on a tape. To request, call
1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. D. TOTAL: (B + C) $ 0.00

Office Use Only APPROVED DATE BY COMMENTS

DENIED

EL007 (5/07)