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Electrician Name: Date: Building#

Immediately notify Supervisor of any condition or conditions that are not within standards, codes, regulations and requirements referenced in the Performance Work Statement that could cause or are likely to cause illness, injury or loss of life if not corrected immediately.

Site:

Details Descri!e the condition of each check point as accepta!le or unaccepta!le.

YES

NO

N/A

"#$$%&'S
Descri!e the violation if it is a (ife safety Issue. )riefly list the required repairs.

Lighting
Properly secured and mounted Evidence of unauthorized removal and relocation Cracked or broken light fixture Evidence of damage or overheating to fixture, tombstone or wiring Number of Bulbs burned out

ther

Receptacles and S itches

!ace plates and boxes damaged or missing Evidence of overheating, damage, discoloration, exposed, or damaged wiring Evidence of unauthorized removal and relocation Properly secured and mounted Exposed or damaged wire from "#C units Evidence of overheating from "#C switch or plug

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ther

Details Descri!e the condition of each check point as accepta!le or unaccepta!le.

"#$$%&'S YES NO N/A

Descri!e the violation if it is a (ife safety Issue. )riefly list the required repairs.

"iring and #a$le

"ll cables#wiring#boxes insulation free from physical damage "ll cables#wiring#boxes properly supported and secured Evidence of unauthorized removal and relocation Evidence of overheating or potential overloading circuits

ther

Electrical %eaters
Evidence of overheating Exposed or damaged connecting wiring Evidence of unauthorized removal and relocation $ater heaters and pumps properly grounded

ith &ags

ther

Details Descri!e the condition of each check point as accepta!le or unaccepta!le.

"#$$%&'S YES NO N/A

Descri!e the violation if it is a (ife safety Issue. )riefly list the required repairs.

'(t(rs and )ans

Page * of 4 Excessive vibration and noise Evidence of overheating Exposed or damaged connecting wiring Evidence of unauthorized removal and relocation

ther

R(ds and +r(unds

Broken, corroded %oes the panel have an e&uipment ground running from the ground bar continues to the metal frame of the structure "re all components properly fastened intact and in good condition Evidence of unauthorized removal and relocation

ther

Electrical ,anel B(-es

"rea surrounding is clear of cluttered, allowing free access to the panel 'nposted or illegible instructions, identification charts, circuit diagrams and feeder schedules Evidence of overheating or potential overloading circuits Broken or missing parts from enclosure Evidence of unauthorized access, removal or relocation "ll cables#wiring insulation free from physical damage Details Descri!e the condition of each check point as accepta!le or unaccepta!le. Check if all panel openings are weather sealed Check cable connectors for exposed wire and proper connection "#$$%&'S YES NO N/A
Descri!e the violation if it is a (ife safety Issue. )riefly list the required repairs.

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Distri$uti(n B(ards
Non(posted or illegible instructions, identification charts, circuit diagrams and feeder schedules Electrical signs and labels present "ll cables#wiring insulation free from physical damage Evidence of unauthorized access, removal or relocation "rea surrounding panel is clear of cluttered, allowing free access to the unit) Broken or missing parts from enclosure *s panel grounded

ther

%mployee Signature
N(tes:

Date