Electrical Operating Permit Renewal and Declaration Form 1218

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Please refer to our website or contact a Regional Office to locate the BC Safety Authority office nearest you. Coquitlam Kelowna Nanaimo Victoria 604-927-2041 250-861-7313 250-716-5200 250-952-4444 fax 604-927-2047 fax 250-861-7349 fax 250-716-5212 fax 250-952-4458 Fax 778-396-2174 Kamloops Langley Prince George 250-314-6000 604-539-3573 250-614-9972 fax 250-377-4406 fax 604-539-3570 fax 250 614 9949
New Westminster
505 - 6th Street, Suite 200, New Westminster, BC, V3L 0E1
Website: www.safetyauthority.ca Fax 1-888-660-3508
Local Phone: 778-396-2000
Toll Free: 1-866-566-SAFE (7233)
Note: The information on this form is collected to administer the provisions of the Safety Standards Act. If you have questions about the collection, use or disclosure of this information, contact the Records, Information & Privacy Analyst at 1-866-566-SAFE (7233).
Invoice #: - Posse supplied Page # - Posse supplied Date – Posse supplied Account # - Posse supplied
Electrical Operating Permit Renewal and Declaration
Permit Class: – Posse supplied -----Pursuant to the Safety Standards Act and Regulations, I wish to renew this (these) permit(s): Permit No. (s) – Posse supplied ------If applicable, attach a list of all service connections with location, voltage, capacity, and permit number. Please complete the attached declaration and return.
Contractor Name (if applicable)
FSR Name
Contractor Number (if applicable)
FSR Number
FSR Class
Pursuant to Safety Standards General Regulation 19(c), I declare that I am the named FSR for this permit(s) and that I acknowledge that I have overall responsibility for work performed under this (these) permit(s). I hereby declare that any work that I have supervised, or performed, complies with the Safety Standards Act and Regulations of British Columbia.
____________________________________________________
Signature of FSR as named above
(FSR or Contractor as applicable)
_________________________________ Date
Provide payment by attaching a cheque or money order and returning by mail to the above address, or arrangements for payment using Visa or MasterCard can be made by calling 1-866-566-7233. If other qualified FSR’s supervise or perform work please attach the long form declaration which can be found on our webpage www.safetyauthority.ca under the Electrical Safety Program Forms tab.
FRM-1218-00 (2009-05-13)
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