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Electrical Safety Certificate

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I certify that the installation, or part installation, to which the Electrical Safety Certificate applies is connected to a power supply and is safe to use.

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Section 1: These questions must be answered “yes” to score a “low risk” job.
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2. Are you trained and competent to complete the job at hand? Yes No
3. Are you wearing the correct PPE for the job at hand? Yes No
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Section 2: These questions must be answered “no” to score a “low risk” job.
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3. Does the job involve working in a confined space? Yes No
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5. Is there the potential for any refrigerant release? Yes No
6. Are there any other Trades, Personnel or Factors affecting the job? Yes No
7. Will your job tasks affect the environment (land, water, air)? Yes No

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I certify that the completed prescribed electrical work to which this Certificate of Compliance applies has been done lawfully and safely, and the information in the certificate is correct in that the installation, or part of the installation: Select those that apply:

By completing this form, I certify that the installation, or part of the installation, to which this Electrical Safety Certificate applies is connected to a power supply and is safe to use.

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