Page 1 of 1 Electrical Certification Deficiencies ReportEP_005_F

Any deficiencies found are noted in the report and have been reported to the Facility Owner/Manager for corrective action. The Electrical Certification Deficiency Form (Insert form number) shall be submitted to the Department of Licenses and Inspections to report any deficiencies requiring correction.

Signature of Inspector :_____________________________________________ Date:____________________

Signature of Facility Owner:__________________________________________ Date:____________________

Deficiency Item Location and Description

Property Information

1 Address: ______________________________________________________________________________________________

2

Name License Number

Email Phone

Address

3

Electrical Certification Deficiencies Report

Electrical Inspection Agency (if applicable) License Number

Electrical Inspector

Deficiency Information

Declaration & Signature

Provide a report of any serious or minor deficiencies that cannot be corrected within 90 days

Provide the address of the facility and name.

Enter name of electrical inspector licensed by the City of Philadelphia and employed by a licensed inspection agency

Facility Name: _______________________________________________________________________

Insert deficiencies that require correction.

OR Full-time licensed electrician by Owner of the facility

Enter the name of the electrical contractor or inspector licensed by the City of Philadelphia who is employed on a full-time basis by the owner of the facility

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