GEORGIA DEPARTMENT OF LABOR

1700 CENTURY CIRCLE, SUITE 100

ATLANTA, GEORGIA 30345

MICHAEL L. THURMOND EARL EVERETT

COMMISSIONER DIRECTOR, SAFETY ENGINEERING

APPLICATION FOR STATE OF GEORGIA

CERTIFICATION OF AUTHORIZATION TO INSTALL,
ALTER, REPAIR OR MAINTAIN ELEVATORS OF WHEELCHAIR LIFTS

Company Name

Mailing Address

Location Name and Address

Telephone No.

Scope of Certificate Requested:
❑ Class I - All Activities of Installation, Alterations, Repairs and/or Maintenance.
❑ Class II - Restricted to Maintenance, Repairs, and Alterations of Elevators
and Installation of Wheelchair Lifts and Residential Elevators.
❑ Class III - Restricted to Installation, Maintenance, and Repairs of Residential
Elevators and Wheelchair Lifts

All information listed below is required to accompany the application. CHECK EACH ITEM.

❑ CERTIFICATE FEE - Amount of Check $

❑ DOCUMENTATION OF QUALIFICATIONS
❑ DOCUMENTATION OF PERSONNEL TRAINING AND EXPERIENCE
❑ GENERAL LIABILITY INSURANCE (INCLUDING PRODUCT LIABILITY) MINIMUM $500,000.00 FOR CLASS
III CERTIFICATE AND $1,000,000.00 FOR CLASS I & II CERTIFICATES.

Type or Print OFFICE USE ONLY

Company
Representative Certificate No.

Telephone No. Expiration Date

Signature Date Issued

Date Signature of State Rep.

The Certificate of Authorization may be suspended or withdrawn by the Chief Safety Engineer after investigation has established the owner failed to follow requirements
set forth in Elevator Rules 300.3.6. When the Certificate is suspended, withdrawn or cancelled, the owner forbids all rights to a refund.

An Equal Opportunity Employer/Program DOL-4261 (6/01)

 PROCEDURES FOR REQUESTING CLASS I, II AND III
CERTIFICATE OF AUTHORIZATION
TO INSTALL, MAINTAIN, REPAIR AND/OR ALTER
ELEVATORS AND WHEELCHAIR LIFTS

1. FEES: Class I - All activites of installation, alteration, repair and/or maintenance. .......... $300.00 Annually

Class II - Restricted to Maintenance, repair and/or alterations of elevators and installation, mainte-
nance, repair and/or alterations to wheelchair lifts, chairlifts and residential elevators. .....
.............................................................................................................. $200.00 Annually

Class III - Restricted to installation, maintenance, repair and/or alterations to residential elevators,
chairlifts and wheel chair lifts. ................................................................ $100.00 Annually

2. The company must provide documentation that it is qualified to perform the activity requested.

3. INSURANCE: Each company must provide proof of general liability insurance, at least $500,000.00 for Class
III and $1,000,000.00 for Class I & II.

NOTE: All documentation and fees must accompany the application for a Certificate of Authorization.

The company, when qualified, will receive a Certificate of Authorization to perform the activity qualified for. The Cer-
tificate of Authorization must be renewed each calendar year prior to April 1, of each year. Companies who do
not renew their Certificate of Authorization will be disqualified to perform any activity and the fee will be doubled when
renewed. Companies who perform any of the activities without qualification will be subject to a $5,000.00 fine.

DEFINITION: Elevators as used in these rules mean: elevators, escalators, dumbwaiters, manlifts, con-
struction personnel lifts and/or moving walks.