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GSM-204-423 Sample form 2: Completion and inspection form
31st Oct 01
Installation & Configuration: Horizon macro outdoor
68P02902W03-A
CONTROLLED INTRODUCTION
Inst. 7–23
Sample form 2: Completion and inspection form
DETAILS OF THE INSTALLATION
Client
:
Address:
DESIGN
I/We being the person(s) responsible (as indicated by my/our signatures below) for the Design of the electrical installation, particulars of which
are described on Page 3 of this form CERTIFY that the said work for which I/we have been responsible is to the best of my/our knowledge and
belief in accordance with the Regulations for Electrical Installations published by the Institution of Electrical Engineers, 16th Edition, amended
to (3.) (date . . . . . . . . .) except for the departures, if any, stated in this Certificate.
The extent of liability of the signatory is limited to the work described above as the subject of this Certificate.
For the DESIGN of the installation:
Name (In block Letters): Position:
for and on behalf of:
Address:
(2.) Signature: (3.) Date
CONSTRUCTION
I / We being the person(s) responsible ( as indicated by my/our signatures below ) for the Construction of the electrical installation, particulars of
which are described on Page 3 of this form CERTIFY that the said work for which I/we have been responsible is to the best of my/our knowledge
and belief in accordance with the Regulations for Electrical Installations published by the Institution of Electrical Engineers, 16th Edition,
amended to (3.) (date . . . . . . . . .) except for the departures, if any, stated in this Certificate.
The extent of liability of the signatory is limited to the work described above as the subject of this Certificate.
For the CONSTRUCTION of the installation:
Name (In block Letters): Position:
for and on behalf of:
Address:
(2.) Signature: (3.) Date
INSPECTION AND TEST
I / We being the person(s) responsible ( as indicated by my / our signatures below ) for the Inspection and Test of the electrical installation,
particulars of which are described on Page 3 of this form CERTIFY that the said work for which I/we have been responsible is to the best of my/
our knowledge and belief in accordance with the Regulations for Electrical Installations published by the Institution of Electrical Engineers, 16th
Edition, amended to (3.) (date . . . . . . . . .) except for the departures, if any, stated in this Certificate.
The extent of liability of the signatory is limited to the work described above as the subject of this Certificate.
For the INSPECTION AND TEST of the installation:
Name (In block Letters): Position:
for and on behalf of:
Address:
I RECOMMEND that this installation be further inspected and tested after an interval of not more than . . . . years (5.)
(2.) Signature: (3.) Date
(6) page 1 of . . . . pages
FORMS OF COMPLETION AND INSPECTION CERTIFICATE
(as prescribed in the IEE Regulations for Electrical Installations)
(1.) (see Notes overleaf)