Electrical Safety – Certificate of Compliance
ONE COPY TO OWNER ONE COPY TO PWC ONE COPY MAINTAINED BY CONTRACTOR FOR 5 YEARS
The customer should retain this certificate as a form of warranty. Should you require any advice about the work set out in this form, contact the licensed
electrical contractor below. Any alterations or additions to installation should be performed by an appropriately licensed person.
Contractor Name:
PWC NIW No:
Contractor Invoice No:
Installation Details – These fields are mandatory
Customer Name:
Address – Property
Address – Postal:
Telephone (a/h):
Telephone (b/h):
Mobile:
Fax:
Type of Installation Work (tick appropriate boxes)
New:
Additions:
Alterations:
Repairs:
Describe Work Certified – Mandatory – Attach addendum sheets as required
Non-Compliances observed on existing installation which were not repaired
Quote Standard and Clause Number for Non-Compliance – Attach other sheets as required
Reported to Electrical Safety Regulator
Electrical Worker
I,
Licence No:
A
certify that the information is complete and correct and that I have carried out all examination and tests on the electrical installation work
detailed on the certificate, and the results satisfy all requirements of the Electricity Reform Act.
Name:
Signature:
Date:
Contractor or Authorised Agent acting on the Contractor’s behalf
I certify the above information is complete and correct and that I have carried out all examinations and tests on the electrical installation
work detailed on this certificate, and the results satisfy all requirements of the Electricity Reform Act.
Business Name:
Licence No:
C
Phone:
Mobile:
Fax:
Name:
Signature:
Date:
Please refer to Information Bulletin Certificates of Compliance – Electrical Safety for more information regarding the issuing of Certificates of
Compliance under the Electricity Reform Act and Electricity Reform (Safety and Technical) Regulations. Verification Sheets are available from NT
WorkSafe website.
V February.2015