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: _______________________