FIR2022-0018 INSPECTION REPORTthyssenkrupp Elevator Corporation
Final Acceptance
This form is to be completed when the elevator(s) are completed. This form must be completed
and presented to the Owner or Owner's Authorized Representative for their signature.
Job/Building Name
Street Address
City, State, Zip Code
Building Phone No.
Building Manager Name
Contract No.
Building Elevator ID No.
Building Elevator ID No.
Building Elevator ID No.
4'
r'-
Please rate thyssenkrupp's job performance:
Factory Serial No. E F U y,T )
Factory Serial No.
Factory Serial No.
❑ Excellent ❑ Good ❑ Fair ❑ Poor
Comments
Date: -7/1 l2 1I
To: thyssenkrupp Elevator
Attn: Billing Department
PO Box 2177
Memphis, TN 38101
Elevator Phone No.
Elevator Phone No.
Elevator Phone No.
Key(s) Received, Key & Key Number .
Independent Hoistway
Service c# Access
Fan/Light 2 J Run/Stop
Fire Service "Z Car Top Exit
Other
We have examined the above listed elevator(s) furnished and completed by you in the above building under the terms of a contract between us dated
. The equipment as installed appears to be satisfactory and in accordance with the contract and we hereby accept it under the terms
and guarantees of said contract and acknowledge receipt of all keys as shown above.
thyssenkrupp Elevator reserves the right to install new remote -monitoring devices or modems on your elevators (each a "Device"). Each Device collects elevator
signal output (i.e., cycle counters, event counters) (the "Raw Data") and/or transfers it into our cloud -based IoT (Internet of Things). The data is then analyzed
by us to assist thyssenkrupp in anticipating maintenance needs on your equipment. Owner authorizes thyssenkrupp to install the Devices and, upon termination
of the service agreement, to remove them from the premises if we elect to do so. thyssenkrupp Elevator shall be the sole owner of the Devices and the data
communicated to us. The Devices shall not become fixtures and are intended to reside where they are installed and should not be accessed, tampered with, or
relocated. thyssenkrupp may remove the Devices and cease all data collection and analysis at any time. If the service agreement between thyssenkrupp
Elevator and Owner is terminated for any reason, thyssenkrupp will automatically deactivate the data collection, terminate the device software and destroy all
raw data previously received. The Devices installed by thyssenkrupp contain trade secrets belonging to us and are installed for the use and benefit of our
personnel only. Owner agrees not to permit Owner personnel or any third parties to use, access, copy, or reverse engineer the Devices. Owner consents to the
installation of the Devices in your elevators and to the collection, maintenance, use, expungement and destruction of the elevator data as set forth in this
agreement.
Accepted By:
Owner/Architect
Type or Print
By
Type or Print
Signature of Authorized Official
Title
Type or Print
Date
thyssenkrupp Representative
Service RT
OFC# #
Special Mech
NIM — ROUTE
Start Date
Purchaser
Type or Print
7 e or Pri t
Signature of Authorized Official
Title 017,-7
TypeorPrint
Date L
Expiration Date
Mo. Day Yr. Mo. Day Yr.
Conditions No. Months Serviced
Hours to be Worked (Scheduled) Wk/Mo
1-wk 2-wk 3-wk 4-wk 5-wk Message
Exams Call Back
Per Yr RT OT
m m
Safety
Test M Print
SUWO v 7 2018 —NI MOD Special Use Work Order/Page 2 of 2
Keep a copy of this form for the thyssenkrupp office, the owner/GC, and your records
f
Department of Labor and Industries ���BTATgoi Elevator Section Inspection Report
e
PO Box 44480 f. ' yr *One Conveyance per Report
Olympia WA 98504-4480
Phone: 360-902-6130
Fax: 360-902-6132
www.Elevators.Lni.wa.gov
New ❑ Alteration ❑ Annual ❑ Non -Annual ❑ 30-Day Permit ❑ Other:
Permit Valid Until __[Permit
ID #
Date Inspection Requested
Date Inspected
Building or Location Name
Conveyance Number and Type
J
Building or Location Address _
Location Number
/
Installer's NameandCity j}
Description of Alternation:
Code Box
Correction Notice A: ❑ A-13
Reinspection Hours
❑ Invoice May Follow
Print Contact Name
Contact's Signature
Contact Phone Number
Print Mechanic's Name
Mec anic's Signature
Mechanic's License Number
Print Inspector's Name )
Inspectot's Signature
F621-002-000 Inspection Report 02-2015 Index EIRPT
White — Central Office Canary — Inspector Pink — On -Site Representative