Annex 4

Test Report

To be filled up by licensed Electrical Contractor

Book No. _______________ Form No. __________________

To be filled up by the licensee

This is being issued for providing electrical connection at the premises of Mr./ Mrs./ Ms.

_________________________________ ______________. The address of the premises  is__________________________ ______________________________________________.

The name and address of the licensed electrical contractor is __________________________

__________________________________________________________________________.

The date of issue of this report is __________________________.

To be filled up by the licensed electrical contractor

5 I hereby declare that –

(a) I have ________________________ class license valid till ______________ .

The license number is _________________________________________.

(b) I have completed this work for Mr./ Mrs./ Ms. _________________________

_____________________for his ____________________________________

______________________________________________________________.

Details of Job

Sl No	Item	220/ 230 Volts						440/ 400 Volts
		Red Phase		Green Phase		Blue Phase		No	Total Watts
		No	Total Watts	No	Total Watts	No	Total Watts

(c)

(i) The particulars of the employees who executed the job are tabulated below.

S.No.	Name of Wireman/ Traniee	Designation	Period
			From	To

The work was carried out under the supervision of

_______________________________ (Supervisor Wireman) whose

certificate number is __________________________________. He

is responsible for work carried out during the period

____________________________________.

(d) This installation specifications adhere to all the provisions of Indian Electricity Rules 1956.

6 I also declare/ certify the following:

(a) The installed switches are of correct ratings: Yes/ No

(b) All the switches and wiring are permanent and of correct specifications Yes/ No

(c) All plugs are of three pin type and controlled by separate switches Yes/ No

(d) All the Single Pole switches connected to the phase Yes/ No

(e) Required permanent mark is provided on the main switch board for Neutral

point Yes/ No

(f) Arrangement for earthing is according to Rule 61 of Indian Electricity Rules,

1956 Yes/ No

(g) In case of three phase installation

(i) Danger board, fire extinguisher with buckets, shock chart and first aid

kit have been provided for Yes/ No

(ii) The installation specifications of the switch board is as per Rule 15 of

Indian Electricity Rules, 1956 Yes/ No

7 Test results

Date of testing_______________________

	Insulation to Earth	Insulation between conductors
Phase 1
Phase 2
Phase 3

Earth Resistance	Date of testing
Electrode No 1	Electrode No 2

8 The date of registration according to form ‘L’ of Madhya Pradesh Licensing Board

(Electricity) is as follows:

Sl No. ____________________________

Date _____________________________

Signature of the Licensed Electrical Contractor

Certificate from Supervisor wireman

It is hereby certified that the aforesaid work has been undertaken by ____________________

________________________________ who has a wireman permit number of ____________

__________________________ that is valid till ___________________________.

It is also certified that testing of the installation has been undertaken by _________________

_________________________________ who has a permit number of __________________

__________________________ that is valid till ___________________________.

Signature of the wireman                                          Signature of Supervisor, wireman

Receipt

The test report form number ____________________for the installation at the premises of

________________________________ prepared by ______________________________

has been received on _________________________________.

Signature of Officer in Charge

Name

Designation

Date