CERTIFICATE FOR EXAMINATION OF

ELEVATOR
QR-08f Rev.1
/09/2018
Certificate Number: Job Order No.: Inspection Standard: BS 81-20:2014

Client Name :
Requested By : Location:

Inspection Type: Initial Periodic Major

Type of Elevator (Description)
Mark and Address of Elevator Manufacturer
Makers Serial No.
Model :
Year of Manufacture : Speed : Ratio :
Model Of Governor : Type of Door:
Wire Rope Dia. : Number of Falls :
Operating Level: Number of Stops: Company ID No.:
Rated Load / Number of Persons Proof Load

Date of Inspection: Date of Next Inspection:

Date of Previous Inspection: Date of last Proof Test:

A. Within a 6 Month Interval

B. Within a 12 Months Interval
The Examination Was Carried Out
C. In Accordance of Examination Scheme
D. After Occurrence of Exceptional Circumstances
Test Procedure Number: TM - 02
Equipment Status: “SAFE TO USE AT THE TIME OF INSPECTION”
Date of Issuance:
Note: This certificate will become invalid, if any alteration / repair or modification is made.

This is to inform that the undersigned inspector or representative attended to examine this machine (equipment) to assure that it is in safe working
condition. Examination indicate that this equipment has no indigenous defects or sighted deformation and is in safe working condition. The said equipment is found to
be satisfactory for further use, provided there is continuous maintenance applied and qualified operators employed.
This certificate is granted subject to the condition that is agreed & understood. Intrepid Safety Consultancies liability shall be limited to the act or
premises of its employees, subcontractors. Under no circumstances whatsoever shall Intrepid Safety Consultancies be liable for any injury or damage to any person or
occurring by reason of negligent operation or any defect in materials, machinery, equipment or other items other than such defects ascertainable normally.
We hereby report that all particulars in this report are correct at the time of test/inspection. Daily inspection & operational maintenance is the sole
responsibility of the users. This certificate shall not be reproduced except in full without written approval of Intrepid Safety Consultancies and Client.

Inspection Engineer: Technical Manager:

 Elevator Inspection Checklist

Items to Check A B C Items to Check A B C

Previous Inspection report Leveling between the sills at a floor
Maintenance log sheet Hall call button operation
Manufacturer manual Housekeeping
MACHINE ROOM CAR TOP HOIST WAY
Machine room (doors, signs, clearance, & accessibility) Emergency stop switch condition
Machine room condition Light (car top and shaft)
Isolator / main breaker (lockable, function) Warning notice, signs & operation instructions
Fire Extinguisher / Sprinkle system condition Inspection control & electrical socket
Electrical layout & its termination Wire rope & terminations condition
Electrical socket (in place and working) Shaft condition
Earth test Landing door condition

Floor condition Door locking device & electrical safety device condition
Machine unit condition (lubricant, gear and data plate) Trap door
Emergency stop switch condition Top run by clearance
Protection guard for moving parts Counter weight condition (rollers & bolts)
Sheave pulley Guide rail & guide shoes condition
Suspension rope and termination condition Supporting structure including bolts and nuts
Hook capacity Compensation chain/rope & termination condition
Brake system Hydraulic hose line
Car upper and lower limit switch from control panel Ram and jack condition
Rope slip test PIT
Governor system (condition & operation) Pit condition
Governor rope and termination Pit light, ladder and function of stop switch
Emergency landing device ( function & condition) Car and CW buffer condition
Emergency Rescue Manual (function & instruction) Run by clearance for CW
Motor Run Timer Limiter (Verify) Safety gear
CABIN INTERIOR Governor tension weight condition
Cabin condition (panel of car, floor, ceiling, sill & trap door) Screen guard for counter weight
Emergency light, Car light, fan, alarm,
Pit partition screen are provided (if two or more lifts)
Intercom & stop switch
Capacity instruction plate as per cabin area Anti-Rebound Device
Car door mechanism Fireman system
Car door (operation, force & clearances) LOAD TEST
Re- opening door device (Sensor) Rated Load
Load control device function (overload) Overload System
Car apron Proof load

Note: A =Satisfactory, B =Unsatisfactory, C =Not Applicable

Remarks & Recommendations:

Fit for Further Use

Equipment Utilized For Test: