A.03.09 GSA Form 376.pdf

PDF 282 KB Posted

Attached to
Elevator Inspections and Maintenance Services Federal contract opportunity
Solicitation number
W9123721Q0001
Issued by
Department of the Army Corps of Engineers Engineering District Huntington

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File Type Posted
B.08.02 W9123721Q0001.pdf PDF
FORM PPQ-0.pdf PDF
A.03.20 PRS_Elevator.pdf PDF

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ELEVATOR INSPECTION REPORT

(Including Escalators and Dumbwaiters) (Read instructions on reverse before preparing report)

BUILDING

STATECITYSTREET ADDRESS

DATE INSPECTION ORDERED

MECHANIC'S SIGNATURE

INSPECTOR'S SIGNATURE INSPECTOR'S TITLE

B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.

BUILDINGS MANAGER'S SIGNATURE DATE

DATE

All elevators, escalators, and dumbwaiters in this building have been inspected by the undersigned inspector on the date noted, and were found to be in a satisfactory condition, except as noted below.

A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING.

(List items below that can be properly performed by force account.)*

THE WORK DESCRIBED ABOVE HAS BEEN COMPLETED, AND THE EQUIPMENT IS READY FOR REINSPECTION, IF REQUIRED

DATE INSPECTION DATE INSPECTION

CERTIFICATES SIGNEDSTARTED:

COMPLETED:

PASSENGER FRT. OR SERV. ESCALATOR DUMBWAITER

REGION

NUMBER OF UNITS IN BUILDING

GSA FORM 376 (11-67)* (Use reverse when more space is required.)GENERAL SERVICES ADMINISTRATION

INSTRUCTIONS

TO

a. Design and Construction Division

b. Buildings Manager - to be forwarded through the regional Buildings Management Division. (One copy to be signed by the mechanic and the Buildings Manager upon completion of the work listed in Section A of the report, and returned to the inspector.

As determined by regional requirements

NUMBER OF COPIES

1. A separate report shall be made for each building for which PBS is responsible for elevator inspections.

2. Distribution of copies:

GSA FORM 376 BACK (11-67)

ELEVATOR INSPECTION REPORT

(Including Escalators and Dumbwaiters) (Read instructions on reverse before preparing report)

BUILDING

STATE

CITY

STREET ADDRESS

DATE INSPECTION ORDERED

MECHANIC'S SIGNATURE

INSPECTOR'S SIGNATURE

INSPECTOR'S TITLE

B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.

BUILDINGS MANAGER'S SIGNATURE

DATE

DATE

All elevators, escalators, and dumbwaiters in this building have been inspected by the undersigned inspector on the date noted, and were found to be in a satisfactory condition, except as noted below.

A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING.(List items below that can be properly performed by force account.)* THE WORK DESCRIBED ABOVE HAS BEEN COMPLETED, AND THE EQUIPMENT IS READY FOR REINSPECTION, IF REQUIRED

DATE INSPECTION

DATE INSPECTION CERTIFICATES SIGNED

STARTED:

COMPLETED:

PASSENGER

FRT. OR SERV.

ESCALATOR

DUMBWAITER

REGION

NUMBER OF UNITS IN BUILDING

GSA FORM 376 (11-67)

* (Use reverse when more space is required.)

GENERAL SERVICES ADMINISTRATION

INSTRUCTIONS

TO

a. Design and Construction Division

b. Buildings Manager - to be forwarded through the regional Buildings Management Division. (One copy to be signed by the mechanic and the Buildings Manager upon completion of the work listed in Section A of the report, and returned to the inspector.

As determined by regional requirements 2

NUMBER OF COPIES

1. A separate report shall be made for each building for which PBS is responsible for elevator inspections. 2. Distribution of copies:

GSA FORM 376 BACK (11-67)

8.2.0.3062.1.452232.445150

BUILDING:
STREET ADDRESS:
INSPECTOR'S TITLE:
A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING. (List items below that can be properly performed by force account.)*:
B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.:
CITY:
STATE:
REGION:
DATE INSPECTION ORDERED. Enter 2 digit month, 2 digit day and 4 digit year.:
DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
DATE INSPECTION CERTIFICATES SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
DATE INSPECTION STARTED. Enter 2 digit month, 2 digit day and 4 digit year.:
DATE INSPECTION COMPLETED. Enter 2 digit month, 2 digit day and 4 digit year.:
NUMBER OF UNITS IN BUILDING. PASSENGER:
NUMBER OF UNITS IN BUILDING. FRT. OR SERV.:
NUMBER OF UNITS IN BUILDING. ESCALATOR:
NUMBER OF UNITS IN BUILDING. DUMBWAITER:
BUILDINGS MANAGER'S SIGNATURE. DIGITAL SIGNATURE.:
A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING. (List items below that can be properly performed by force account.)* Continued from page 1.:

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