Cqcc Form 4R – Fill Out and Use This PDF

The State of California CQCC #CC - Certified Qualified Conveyance (Elevator) Company (CQCC) Application for Renewal is a form designed for businesses involved with the installation, maintenance, repair, and service of elevators and other conveyance systems. It outlines the necessary information and documentation required for companies seeking to renew their certification to operate within the state. This streamlined process ensures that only qualified and compliant businesses are able to provide safe and reliable conveyance services. Be sure to complete this essential form by clicking the button below to maintain your certification and continue serving the California community.

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Cqcc Form 4R PDF Details

The State of California recognizes the critical importance of maintaining safety and operational standards in the conveyance (elevator) industry, prompting the need for a streamlined certification renewal process for Certified Qualified Conveyance Companies (CQCC). The CQCC 4R form serves as a vital tool for companies engaged in the installation, alteration, service, repair, or maintenance of elevators and related conveyance systems, enabling them to renew their certification effortlessly. This comprehensive form addresses various critical aspects, from basic company information to detailed qualifications of the personnel involved, ensuring that companies remain compliant with the state's stringent safety regulations. It requires companies to specify their business nature, provide evidence of relevant licenses, and demonstrate their commitment to adherence to applicable codes. Furthermore, the form delves into the qualification history and educational backgrounds of key personnel, underscoring the importance of continuous learning and adherence to the latest industry standards. Submission of the form, accompanied by necessary documentation such as proof of insurance and a current elevator contractor's license, finalizes the renewal process, reinforcing the company's capability and readiness to deliver safe, reliable conveyance services in California.

Question	Answer
Form Name	Cqcc Form 4R
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	ASCE, list of certified qualified conveyance companies in california, CSLB, California

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State of California			CQCC # CC	-
Certified Qualified Conveyance (Elevator) Company (CQCC)
Application for Renewal			Date ______________

	1. Company Information
Specify nature of business (more than one box may be checked if appropriate).
	Installation/Alteration	Service or Maintenance	Repair

Specify form of business:

Corporation Partnership

Limited Liability Company (LLC)

Sole Ownership with employees

Sole Ownership with no employees

Public Entity

__________________________________________________________		___________	___________	________________________
Business/Company Name		Classification	CSLB #	Lic. Exp. Date (mm/dd/yyyy)
__________________________________________________________		______________________________________________________
Business/Company Address		(City, State, Zip + 4)
_____________________________________	__________________	(_______)___________________ _________________________
Business Officer/ Partner/ Sole Owner	Title	Phone		email address
__________________________________________________________		______________________________________________________
Residence Address		(City, State, Zip + 4)
_____________________________________	__________________	(_______)_________________		_____________________ ____
Business Officer/ Partner	Title	Phone		email address
__________________________________________________________		______________________________________________________
Residence Address		(City, State, Zip + 4)

Company maintains copies of all applicable codes related to the conveyances erected, constructed, installed, materially altered, tested, maintained, repaired or serviced by the company. All branch and field offices of the company in the State of California shall have these codes available for use by any CCCM employed by the company.

2. Certification Type

Applicant understands that this Certification does not release the applicant from obtaining any other license which may be required by the California State Licensing Board or any other agency.

General Certification. This certification qualifies the applicant through their designated individual as a CQCC on all conveyances covered by California Labor Code, Part 3, Chapter 2. The application must be completed including endorsement by the company in Section 4 and submitted to the Division for processing.

Limited Certification. The applicant should check the appropriate box or boxes, complete the application including endorsement by the company in Section 3, and submit the application to the Division for processing. This certification limits the applicant through their

designated individual as a CQCC on specific conveyances. Any company with limited certification that works on conveyances beyond those, for which the company has been certified, may risk losing the company’s certification.

Elevators

Platform Lifts and Inclined Stairway Chair Lifts

Vertical and Inclined Reciprocating Conveyors Funiculars

Belt Manlifts

Material Lifts and Dumbwaiters with Automatic Transfer device

Escalator and Moving Walk Special Access Elevators

Automated People Movers as defined by ASCE 21 Other Automatic Guided Transit Vehicles on Guideways Dumbwaiters

Special Purpose Personnel Elevators

Page 1 of 4

CQCC Form 4R (Rev. 4/30/12)

provide a copy

Additional Information:

State of California

Certified Qualified Conveyance (Elevator) Company (CQCC)	Renewal Application

3. Qualification History (1st Qualifier)
1st Qualifier Name ______________________________________

Experience. Describe duties and dates of employment since last renewal evidencing experience in the conveyance industry performing construction, maintenance, service or repair of conveyances covered by Chapter 2 of Part 3 of Division 5 of the California Labor Code.

Note: Any change in Qualifiers will require the use of a full CQCC application not the renewal application.

Current or Most Recent Employer

	From (mm/yy)	To (mm/yy)	Job title

	Hours per week	Total worked (years/months)	Company	CSLB No.

				CQCC No.

	Supervisor	Phone	Address

	Description of Duties (Be specific to type of device.)

Previous Employer

	From (mm/yy)	To (mm/yy)	Job title

	Hours per week	Total worked (years/months)	Company	CSLB No.
	Hours per week	Total worked (years/months)	Company
				CQCC No.

	Supervisor	Phone	Address

Description of Duties (Be specific to type of device.)

4. Current or Most Recent Employer's Verification of Experience

I certify under penalty of perjury that the aforementioned employment experience is verified as true and accurate information .

Signature

Print Name

Title

Date

5. Education and Training

Explain or list additional skills, aptitudes, educational courses or degrees that may qualify you as a Certified Competent Conveyance

Mechanic in the State of California. List trade certifications, continuing education training courses and other certifications. Include dates of training and

of course certificate showing evidence of total hours of attendance. A minimum of 8 hours of instruction from an approved continuing education course provider, covering new and existing provisions of the regulations of the board is required. Continuing education shall occur within one year immediately preceding certificate renewal.

____________________________________________________________

Page 2 of 4

CQCC Form 4R (Rev. 4/30/12)

Additional Information:

State of California

Certified Qualified Conveyance (Elevator) Company (CQCC)	Renewal Application

6. Qualification History (2nd. Qualifier)

2nd Qualifier Name ______________________________________

Note: Any change in Qualifiers will require the use of a full CQCC application not the renewal application. Current or Most Recent Employer

	From (mm/yy)	To (mm/yy)	Job title

	Hours per week	Total worked (years/months)	Company	CSLB No.

				CQCC No.

	Supervisor	Phone	Address

	Description of Duties (Be specific to type of device.)

Previous Employer

	From (mm/yy)	To (mm/yy)	Job title

	Hours per week	Total worked (years/months)	Company	CSLB No.
	Hours per week	Total worked (years/months)	Company
				CQCC No.

	Supervisor	Phone	Address

Description of Duties (Be specific to type of device.)

7. Current or Most Recent Employer's Verification of Experience

I certify under penalty of perjury that the aforementioned employment experience is verified as true and accurate information.

Signature

Print Name

Title

Date

8. Education and Training

Explain or list additional skills, aptitudes, educational courses or degrees that may qualify you as a Certified Competent Conveyance

Mechanic in the State of California. List trade certifications, continuing education training courses and other certifications. Include dates of training and provide a copy of course certificate showing evidence of total hours of attendance. A minimum of 8 hours of instruction from an approved continuing education course provider, covering new and existing provisions of the regulations of the board is required. Continuing education shall occur within one year immediately preceding certificate renewal.

____________________________________________________________

Page 3 of 4

CQCC Form 4R (Rev. 4/30/12)

State of California

Certified Qualified Conveyance (Elevator) Company (CQCC)

Renewal Application

9. Required Documentation

The applicant shall attach a copy of the following documentation necessary to complete the processing of this application. Any documentation not submitted will result in a delay of the certification process.

Current elevator contractors license pursuant to Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, if required by nature of business.

A list of branch offices conducting business in the State of California. This list shall include the branch office business address, contact name, contact telephone number, fax number, and email address (if available).

Policy or certificate of insurance for general liability coverage of not less than one million dollars ($1,000,000) for injury or death of any one person or persons in any one occurrence, and with coverage of not less than five hundred thousand dollars ($500,000) for property damage in any one occurrence.

Policy or certificate of insurance of worker’s compensation insurance coverage, if applicable.

10. Company Affidavit

I certify under penalty of perjury that the information disclosed in this application, including employment experience of the qualifying individuals is verified as true and accurate information.

_______________________	_____________________________________________________			___________________________
Business Officer Signature		Print Name	Title	Date (mm/dd/yyyy)
_______________________	_____________________________________________________			(______)___________________
Company Name		Address (City, State, Zip + 4)		Phone
_______________________	______________________________________________________			__________________________
Business Officer Signature		Print Name	Title	Date (mm/dd/yyyy)
_______________________	_____________________________________________________			(______)___________________
Company Name		Address (City, State, Zip + 4)		Phone

The application fee for the Renewal Certification shall be one hundred forty dollars ($140.00) per California Code of Regulations, Title 8, Section 344.30. The fee shall be attached to this application as a check made out to the Department of Industrial Relations, Elevator Safety Account. Any changes or updates to the original application require the company to reapply using application CQCC Form 4 available from the Division. All fees are non-refundable as provided in California Labor Code section 7311.4(b).

Note: A company operating as a CQCC shall not hold concurrent certification as a CQCIC.

Completed applications may be returned to the following address:

State of California

Division of Occupational Safety and Health

Elevator, Ride and Tramway Unit, Certification Section

2424 Arden Way Suite 485

Sacramento, CA 95825
Phone: (916) 274-5709	Fax (916) 263-1957

Page 4 of 4

CQCC Form 4R (Rev. 4/30/12)

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This form will require particular information to be typed in, therefore be certain to take whatever time to fill in what is expected:

1. To get started, when filling in the Lic, beging with the page that has the subsequent fields:

2. The subsequent step is usually to fill in the next few blanks: BusinessCompany Name CSLB Lic, City State Zip, City State Zip, Title, email address, Phone, Company maintains copies of all, tested maintained repaired or, General Certification This, covered by California Labor Code, and Limited Certification The.

People who work with this form often make errors while filling in City State Zip in this area. Ensure you read again whatever you enter right here.

3. This next part should also be rather straightforward, Elevators Platform Lifts and, Escalator and Moving Walk Special, Page of, and CQCC Form R Rev - every one of these empty fields will need to be completed here.

Elevators Platform Lifts and, Page of, and CQCC Form R Rev of 2nd

4. The next section requires your information in the subsequent places: Job title, To mmyy, Total worked yearsmonths Company, State of California Certified, Total worked yearsmonths Company, To mmyy, Address, Job title, Phone, CSLB No, CQCC No, CSLB No, and CQCC No. Just remember to fill in all of the needed info to move onward.

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Cqcc Form 4R – Fill Out and Use This PDF

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