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HOMEOWNER VERIFICATION FOR ELECTRICAL WIRING PERMITS
C V, s - a states the following:
priht your full name on line above:
1. I am the owner of the single family dwelling for which I am applying for an
electrical permit.
Address: C 1 0 �tr
2. I am applying for an electrical permit for a single family dwelling and it is or will
be my principal residence.
3. I will install and connect the electrical wiring for myself, without compensation
or pay from or to, any other person.
4. 1 have sufficient knowledge of the 2005 National Electrical Code requirements to
make an electrically safe and mechanically secure installation which will meet the
minimum standards referenced in 81 -2104.
5. I am aware of all inspections required prior to a final.
6. I will call twenty -four (24) hours in advance for an inspection. I am also aware
that it is not the inspector's job or duty to be my instructor in electrical wiring.
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7. I am aware that Nebr. Rev. Stat. 81 -2143 makes it a Class 1 misdemeanor to
make a false statement on a request for inspection.
8. By signing this form I am stating the above information is true an correct.
Horn li t Signature Date
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218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 • Fax 402 - 426 -4195 E -mail cityofblair @ci,blair.ne,us Eo