Request for Variance - Elevating Devices Form 1007

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BC Safety Authority New Westminster Office: 505 Sixth Street, Suite 200 New Westminster, BC V3L 0E1
Local Number: 778-396-2000 Local Fax: 778-396-2064 Toll Free: 1-866-566-SAFE (7233) Web site: www.safetyauthority.ca
REQUEST FOR VARIANCE - ELEVATING DEVICES TECHNOLOGY
The information on this form is collected to administer the provisions of the Safety Standards Act and Elevating Devices Safety Regulation. If you have any questions about the collection, use, and disclosure of this information, contact the Records, Information & Privacy Analyst at 1-866-566-SAFE (7233).
General Information Date of Request:__________________________ Applicant: ___________________________ Company: (where applicable) ________________________________________________________ Address:____________________________________________________________________ City: __________________Postal Code:_______ Phone/Email: ________________________ BCSA Unit Number:(where applicable) ____________________ Bldg. Name: _________________________ Site Address: ________________________________________________________________ City: _______________________________________________________________________
Details of Variance:
(Check relevant)
□ Applicable Code Clause(s):___________________________________________________ □ Safety Standard Act & EDSR: ________________________________________________ □ Safety Officer Certificate of Inspection: _________________________________________
Reason for variance request: (Attach separate sheet if required) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Alternative Proposed and Proof of Equivalency. How will equivalent safety be provided?
(Present supporting documents)
___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
FRM-1007-03 (2010-10-05)
BC Safety Authority New Westminster Office: 505 Sixth Street, Suite 200 New Westminster, BC V3L 0E1
Local Number: 778-396-2000 Local Fax: 778-396-2064 Toll Free: 1-866-566-SAFE (7233) Web site: www.safetyauthority.ca
Review: Licensed Elevating Devices Contractor Review Contractor Name: ______________________ Contractor’s Officer Name: ________________ Phone:_______________________________ Email: ________________________________ Signature: ____________________________ Date: _________________________________ Comments: _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
BCSA Elevating Devices Office Use Only
□ Approved
□ Rejected
Reviewed By:__________________________Title: __________________________________ Phone: ______________________________ Email:_________________________________ Signature: ____________________________ Date:__________________________________ Comments:__________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Terms and Conditions: ________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
FRM-1007-03 (2010-10-05)