Title Page
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Document No.
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Conducted on
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Job Name
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Job Address
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Location Number and Contact
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Prepared by
Elevator Information
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Elevator Name/Number
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State Number
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Type of Elevator
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Elevator Manufacturer
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Stops/Openings
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Last 5 Year Load Test
Machine Room
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Cleanliness
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Starter Contacts
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Controller Cleanliness
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Controller Jumpers
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Relay Covers Installed
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Valve and Misc. Covers
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Oil Leaks, pump, valve, line
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Floor Painted
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Spare Parts
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Check Charts Current
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Controller Fuses (correct amps)
Hoistway
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Fire Test Charts Current
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Cleanliness
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Rails Lubricated
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Door Tracks Clean and Lubricated
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Covers Installed
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Sills Clean (check behind doors)
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Hall Door Noise
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
Cab
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P/U Rollers Adjusted and Lubricated
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Cleanliness
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Cartop Clean Painted
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Door Linkage Lubricated
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Safe Edge and Photo Eye Operational
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Car Door Chains/Belts Adjusted
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Car Door Operation
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Car Door Clutch Clean and Lubricated
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Car Door Rollers
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Car Door Tracks
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Cartop Lights Operational
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COP LEDs and PI
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Emergency Phone Operational
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Stop Switch Operational
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Car Guides
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Ride Quality
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
Pit
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Cleanliness
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Packing
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Buffers
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Pipe Stands
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Lights
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Pit Can
- Good
- Fair
- Poor
- Acceptable considering overall condition of equip
- No Obvious Jumpers
- Not Applicable
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Notes