Fillable 5023 060 5023-060 Service Maintenance Contract Verification

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5023 060 5023-060 Service Maintenance Contract Verification

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DBPR Form HR-5023-060 – Verification of Service Maintenance Contract
Page _____ of _____
2013 July 9 61C-5.013, F.A.C. Page 1 of 2
STATE OF FLORIDA, DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
Division of Hotels and Restaurants, Bureau of Elevator Safety
2601 Blair Stone Road, Tallahassee, FL 32399-1013
Phone: 850.487.1395 – E-mail: dhr.elevators@myfloridalicense.com Internet:
www.MyFloridaLicense.com/dbpr/hr
Please direct questions about this application to the Department of Business and Professional Regulation’s Customer
Contact Center at 850.487.1395. Information is also available online at www.MyFloridaLicense.com/dbpr/hr/
.
Section 1 – Service Maintenance Company Information
Registered Elevator Company (REC) Name REC License Number
City County State Zip Code
Section 2 – Service Maintenance Contract Information
1
s
t
Buildin
g
Annual Verification Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
2
nd
Building
Annual Verification Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
3
rd
Building
Annual Verification Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
Section 3 – Authorized Signature
Pursuant to Section 399.061(1), Florida Statutes (F.S.), the undersigned verifies the existence of service maintenance
contract(s) that comply with Section 399.01(10), F.S., and Section 61C-5.013, F.A.C., for the specified elevator(s).
Signature of Authorized Representative Date Signed
Please attach additional pages as necessary. Indicate the number of pages at the top of each page.
Submit the completed form
to the Bureau of Elevator Safety at the e-mail or mailing address listed above.
DBPR Form HR-5023-060 – Verification of Service Maintenance Contract
Page _____ of _____
2013 July 9 61C-5.013, F.A.C. Page 2 of 2
Section 4 – Additional Buildings
Building _____
Annual Verification
Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
Building _____
Annual Verification
Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
Building _____
Annual Verification
Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
Building _____
Annual Verification
Building Name
Cancellation or Expiration
Street Address
City County State Zip Code
Elevator
License Number(s)
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5023 060 5023-060 Service Maintenance Contract Verification

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Completed 3 July 2020

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