Electrical Contractor License Application Form 1028

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PRINTED IN B.C.
4500142120
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TOLL FREE NUMBER: 1.866.566.SAFE (7233) www.safetyauthority.ca
3rd Floor, 4243 Glanford Avenue Unit 24 604-927-2041 fax Kamloops Coquitlam - 2773 Barnet Highway 604-927-2047 Victoria, BC V8Z 4B9Langley Coquitlam, BC V3B 1C2 250-861-7313 fax 250-861-7349 Kelowna 250-716-5200 Prince George Nanaimo Mainland South Regionalfax 250-716-5212 Lower Office: Northern Interior Regional Office: 250-952-4444 fax 250-952-4458Westwood Drive Victoria Fraser Highway 3235 20635 Langley, BC V3A 4G4 Prince George, BC V2N 1S4
Vancouver Island Regional Office: Southern Interior Regional Office: Lower Mainland North or contact a Regional Office to locate the BC Safety Authority office nearest you. Please refer to our web siteRegional Office: 1913 Kent Road 250-377-4406 250-314-6000 fax Kelowna, BC fax 604-539-3570 604-539-3573 V1Y 7S6 250-614-9972 Head Office: fax 250 614 9949 88 - 6th Street, Suite 400 New Westminster, BC V3L 5B3
Website: www.safetyauthority.ca fax 1-888-660-3508
New Westminster: 505 - 6th Street, Suite 200, New Westminster, BC, V3L 0E1 Local Phone: 778-396-2000 fax 778-396-2174 Toll Free: 1-866-566-SAFE (7233)
ELECTRICAL CONTRACTOR LICENCE APPLICATION
Note: The information on this form is collected to provisions the the BC Safety Standards Act. If youAct. If you have any questions the collection, use, use, or disclosurethisthis information, contact the This form is collected to administer the administer of provisions of the BC Safety Standards have any questions about about the collection, or disclosure of of information, Records/FOIPP Coordinator for the BC Safety Authority at for the BC Safety Authority at telephone 1-866-566-SAFE (7233). contact the Records, Information & Privacy Analyst telephone 604-660-6286. Fees payable to thethe BC Safety Authority. Fees payable to BC Safety Authority.
LICENCE NO.
EXPIRY DATE
LICENCE FEE
$
HAVE YOU CONSIDERED USING BC ONLINE (www.bconline.ca 1.800.663.6102) OR OUR TOLL FREE NUMBER 1.866.566.7233 WHEN APPLYING FOR YOUR PERMITS?
FOR APPLICANT USE
(NAME OF THE LICENCED ELECTRICAL CONTRACTOR (EC) SHOWN ON THIS APPLICATION MUST BE THE SAME AS ON THE BOND). PLEASE PROVIDE BUSINESS CONTACT INFORMATION.
CONTRACTOR NAME
MAILING ADDRESS
SUITE NO. STREET NO. STREET NAME STREET TYPE
CITY TELEPHONE ( ) FAX (
PROVINCE )
POSTAL CODE E-mail
SAFETY STANDARDS ACT AND REGULATIONS Surety Bond
For a new application, include the original bond bearing principal’s signature and insurer’s signature and seal. For any changes to an existing bond or for a change in the bond insurer, the original bond bearing principal’s signature and insurer’s signature and seal must be filed with the BC Safety Authority.
NOTE: BOND IN THE AMOUNT OF $10,000.00 MUST BE PROVIDED BY A SURETY, LICENCED UNDER THE INSURANCE ACT AND BOUND TO THE BC SAFETY AUTHORITY.
I have read and understand my duties, responsibilities and obligations as a registered electrical contractor under the Safety Standards Act & Regulations. I hereby appoint the following person to be the field safety representative. All information provided is true and correct. By signing below, I give consent to the BC Safety Authority to verify and disclose the information provided on this form for the purposes consistent with the administration of the Safety Standards Act.
NAME
(PERSONAL APPLICANT OR AUTHORIZED COMPANY REPRESENTATIVE. PLEASE PRINT)
SIGNATURE
DATE
(YYYY / MM / DD)
NUMBER OF CARDS REQUIRED
FIELD SAFETY REPRESENTATIVE (FSR) REPRESENTING THE ELECTRICAL CONTRACTOR
FSR NAME
(PLEASE PRINT)
FSR CLASS(ES)
REGISTRATION NO.
FSR CONTACT/ MAILING ADDRESS
(PLEASE PRINT)
CITY
PROVINCE
POSTAL CODE
I have read and understand my duties, responsibilities and obligations under the BC Safety Standards Act & Regulations to be the field safety representative (FSR) for the above named electrical contactor. I am registered as a field safety representative and hold a valid FSR certificate with the class(es) noted above. I am employed by the above named registered electrical contractor. By signing below, I give consent to the BC Safety Authority to verify and disclose the information provided on this form for the purposes consistent with the administration of the Safety Standards Act.
FSR SIGNATURE, ACCEPTING APPOINTMENT DATE
(YYYY / MM / DD)
FOR OFFICE USE
I have verbally confirmed the acceptance of the Field Safety Representative position with the above named Field Safety Representative.
NAME OF CSR or ELECTRICAL SAFETY OFFICER: OFFICE
SIGNATURE
DATE
(YYYY / MM / DD)
TECHNOLOGY PYMT. METHOD ENTRY DATE
Y Y Y
EL
FILE NUMBER FEE (TOTAL)
0 0
PROCESSED BY
Y
M
M
D
D
FRM-1028-02 (2009-05-08) FRM-1028-01 (2006/08/01)
Return completed form and fee to the BC Safety Authority in your area. White - Head Office Yellow - Audit Pink - Customer