Electrical Contractor Authorization and Declaration Form 206 (PDF)

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PRINTED IN B.C.
4500158979
232201
TOLL FREE NUMBER: 1.866.566.SAFE (7233) www.safetyauthority.ca
Vancouver Island the BC Safety Authority office nearest you. Regional Office: Lower Mainland North Regional Office: Regional Office to locateRegional Office: Southern Interior Please refer to our web site or contact a 3rd Floor, 4243 Glanford Avenue Unit 24 - 2773 Barnet Highway 1913 Kent Road fax 250-377-4406 250-314-6000 604-927-2041 fax 604-927-2047 Kamloops Coquitlam Victoria, Coquitlam, BC V3B 1C2 Kelowna, BC V1Y 7S6 604-539-3573 fax 604-539-3570 250-861-7313 fax 250-861-7349BC V8Z 4B9 Langley Kelowna 250-614-9972 fax 250 614 9949 Lower Mainland South Regional Office:250-716-5212 Interior Regional Office: Northern Head Office: 250-716-5200 fax Prince George Nanaimo fax 250-952-4458 Victoria 101 - 22259-48th 250-952-4444 Avenue 3235 Westwood Drive 88 - 6th Street, Suite 400 Langley, BC V3A 8T1 Prince George, BC V2N 1S4 New Westminster, BC V3L 5B3
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)
Website: www.safetyauthority.ca fax 1-888-660-3508
ELECTRICAL CONTRACTOR AUTHORIZATION AND DECLARATION OF COMPLIANCE ELECTRICAL INSPECTION REQUEST
This information on this form is collected to administer the provisions of the BC Safety Standards Act. If you have questions about this information, Note: The form is collected to administer the provisions of the BC Safety Standards Act. If you have any questions about the collection, use, or disclosure of the collection, use or disclosure thethis information, contact the Records/FOIPP Safety Authority atthe BC Safety Authority at telephone 604.660.6286. contact of Records, Information & Privacy Analyst for the BC Coordinator for telephone 1-866-566-SAFE (7233).
A.
Installation (If faxing this document, please PRINT clearly):
Permit Number: Installation name: Suite no.: City: Civic no.: Street name: Location of Work Site: Street type: NSEW:
B.
Licensed Electrical Contractor:
Licensed Electrical Contractor (EC) name (please print): License No.: City: Telephone: ( ) Fax: ( )
C.
Declaration (to the electrical inspection office/and supply authority):
FSR Classes:
Field Safety Representative No. (FSR):
“I ______________________________________________ a field safety representative for the above licensed contractor, hereby declare that the electrical installation authorized under the above mentioned permit has been installed to comply with the Safety Standards Act and Regulations of British Columbia.” Field Safety Representative (FSR) Signature: Date:
YYYY MM DD
Work in Progress Rough Wiring Inspection Required Rough Wiring Progress: Partial Complete Electrical Installation Ready New Service Service Change Type of grounding electrode: Voltage (line to line) V Non Compliance Corrected From: Rod AMPS A Ufer Plate Temporary Construction Service To: Rough Wiring Cover Date: Slab
All work is Complete
YYYY MM DD
Installation Safe
UFER Ground
Under Ground
Partial Rough Wiring Area:
Service Repair
Other-describe: Phase O
YYYY MM DD
Electric Heat kw
Non Compliance of Corrected Date:
Remarks:
RE-INSPECTION FEES MAY BE ASSESSED WHEN AN INSPECTION OF A PREVIOUS NON-COMPLIANCE IS PERFORMED (MIN. 1 HOUR WILL BE CHARGED).
White - (Top copy) Applicable inspection authority
FRM-0206-05 (2009-05-08) FRM-0206-04 (2007/12/19)
Green - Job site
Pink - Supply authority (where applicable)
White - Electrical Contractor’s