Form /1
Serial No.
INSTALLATION ADDRESS
The extent of liability of the signatory is limited to the work described above as the subject of this certificate. Signature.. Date//..... Name. Particulars of signatory (note 3)
Position: Company: postcode: Address:
NEXT INSPECTION
I recommend that this installation is further inspected and tested after an interval of not more than
Year / Months
a.c.
1-phase, 2-wire pole 1-phase, 3-wire pole 2-phase, 3-wire other 3-phase, 3-wire 3-phase, 4-wire
d.c.
23-
Nominal voltage, U/U0 V Nominal frequency, f Hz Prospective fault current, Ipf KA External loop impedance, Ze
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(note 5)
PARTICULARS OF INSTALLATION REFERRED TO IN THIS CERTIFICATE Means of Earthing Maximum Demand Distributors facility Installation earth electrode Maximum Demand (load) = Type (e.g. rods(s), tape etc) A Location Amps per Phase = A Details of Installation Earth Electrode Electrode resistance to earth connection verified connection verified
Main Protective Conductors Earthing Conductor Main equipotential Bonding conductors material: material: conductor csa: conductor csa: mm2 mm2
Main Switch or Circuit-Breaker B.S. Type Location: Rated residual operating current I
n
No. of poles:
Current Rating:
Amps
Volts
ms at 5I
SCHEDULES (note 2)
The attached Schedules are part of this document, and this certificate is only valid when they are attached to it.
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