ZELIENOPLE BOROUGH

 

"VERIFICATION OF ELECTRICAL INSPECTOR CERTIFICATION"

 

Name:                                                                                                        Phone:

Address:                                                                                                     Fax:

City:                                 State:                                 Zip:                           E-mail:

 

Firm Name:                                                                                                Phone:

Address:                                                                                                     Fax:

City:                                 State:                                 Zip:                           E-mail

 

Are you certified by the Pennsylvania Department of Labor and Industry in the following?

Code #11, Residential Electrical Inspector, pursuant to 34 Pa. Code §401.7(2) Yes/No

Certification #: Issue: Exp.:

Code #19, Commercial Electrical Inspector, pursuant to 34 Pa. Code §401.7(7) Yes/No

Certification #: Issue: Exp.:

Electrical Plans Examiner, pursuant to 34 Pa. Code §401.7 (14) Yes/No

Certification #: Issue Exp.:

PLEASE PROVIDE PROOF OF ALL CERTIFICATIONS—ATTACH TO THIS FORM

Are you insured pursuant to 34 Pa. Code §401.12? Yes/No Valid: Exp.:

PLEASE PROVIDE PROOF OF INSURANCE—ATTACH TO THIS FORM

Are you bonded? Yes/No Municipality: Amount:

PLEASE PROVIDE PROOF OF BONDING—ATTACH TO THIS FORM

Are you listed with the Pennsylvania Department of Labor and Industry as a Code Administrator

under 34 Pa. Code §401.13?: Yes/No And certified pursuant to 34 Pa. Code §401.3 and

§401.11?: Yes/No

PLEASE PROVIDE PROOF OF CERTIFICATION AND DOCUMENTATION FOR ALL AFFIRMATIVE ANSWERS.

I hereby certify that the information provided above is true and correct to the best of my knowledge.

Signature______________________________________ Date______________________

(Office use only)

Received by: ___________________________ Comments:

Date: _______________________

 

 

Permits/Applications

Code Enforcement