Department of Electrical Inspectorate, Haryana

Application Forms

Sr. Application Forms

No.
1 Application Form for grant of Electrical - Appendix-I
Supervisor/Competency Certificate (Exemption).

2 Application for grant of Electrical Contractor Licence - Form ‘D’

Class ‘A’.

3 Application for Duplicate Permit/ Certificate/ Licence. - Appendix-II

4 Application for renewal of Electrical Contractor License - Appendix-III
Class ‘A’.

5 Application for renewal of Wireman Permit and Supervisor - Appendix-IV

Competency Certificate.

6 Application for up-gradation of Supervisor Competency - Appendix-V

Certificate.

7 Application format for Inspection of EHV Electrical - Form ‘A-1’

Installation for approval of energisation.

8 Application format for Inspection of EHV Overhead - Form ‘B-1’

Transmission Lines for approval of energisation.

9 Application format for inspection of HT (upto 33KV) - Form ‘A-2’

installation for approval of energisation.

10 Application format for inspection of HT (upto 33KV) lines - Form ‘B-2’

for approval of energisation.

11 Application for Periodical Inspection of Electrical - Form ‘C-1’

installation.

12 Application form for Registration to Work the - Form A, B, C

Lift/Escalator
&E
 Appendix-I
State Licensing Board, Haryana
Application for grant of Electrical Supervisor Competency Certificate (Exemption)
1. Name of Applicant

Sex:

2. Name of Father

3 Permanent Address

PIN

4 Address for Communication

PIN

5 District

6. Date of Birth Date Month Year Age

7. Educational Qualifications
8. Technical Qualifications
9 Name and Address of Institutions in which the candidate has studied for Tech. Qual.
10 Whether the candidate is holder of Electrical Supervisor Competency Certificate issued by
any State Licensing Board. If so, give details

Category Permit number Date of issue with Validity

 11. Details of Experience

12 Are you employed on permanent basis? If so, give details

13 Details of Fee
Amount Challan Number Date Name of Treasury

I hereby declare that the particulars stated above are correct to the best of my knowledge . I am not a holder of
Supervisor Competency Certificate issued by the State Licensing Board other than those indicated in the
column 10. I also agree to the cancellation of my Competency Certificate that may be issued to me in
pursuance of this application in case the particulars furnished in the application are found incorrect or false.

Place
Signature of Applicant
Date

Photocopies of documents to be forwarded alongwith the application:-

a) Matriculation certificate indicating date of birth.
b) Degree in Electrical Engg. or equivalent.
c) Residence Proof.
d) I D Proof.
e) Photographs 2 Nos.
f) Medical fitness certificate in case age is above 55 years.
g) Copy of retirement orders for retired engineers.
h) Specimen signatures 3 Nos.
i) Treasury Challan of Rs 290/- deposited in any treasury of Haryana under Head of account :- ‘0043-Taxes and
Duties on Electricity –Other Receipts fees payable under I.E. rules, 1956”.
 FORM-D

STATE LICENSING BOARD HARYANA

APPLICATION FOR ELECTRICAL CONTRACTOR LICENCE
CLASS ‘A’
1 Name in which Electrical Contractor Licence is applied for
2 Business Address-
Pin Code-
E-mail-
Phone No-
3 Style of the Company
a) Proprietary concern/company /firm registered under
the Companies Act.
b) If company/firm, attach documents to prove the
status of the firm/company
4 Whether the company has a registered office in Haryana/UT
Chandigarh/NCT Delhi
5 Full name and address of Proprietor or partners/ Directors
1
2
3
4
5
6 Full name of Agent or Manager
( in the case of Limited Company)
7 Whether the applicant is a manufacturing firm or production
unit.
8 Name of the authorized person signing documents
9 Whether a contractor licence has been previously granted in
the same name ? If yes, give details thereof.
10 Whether a contractor Licence has been issued under this
name by any other State Licensing Board ? If so, please give
name of issuing Authority-
Date of issue-
Date of expiry of Licence-
Details of works permitted to be undertaken-
11 Whether adequate drawing office facilities for preparation of
drawings, blue prints etc. is available.
12 Whether the staff indicated under column 13 are exclusively
earmarked for the work under the Licensing Board and
Regulation 29 of “Central Electricity Authority (Measures
relating to Safety and Electric Supply) Regulations 2010”.
13 Name of all persons employed full time basis having technical qualifications and experience
that are approved by the Board for the grant of Class ‘A’ licence.
Sr. No. Name of person Qualification Certificate and permit Whether declaration in
with their No. and the form appended
validity date. have been attached

14. Library:
(a) Electricity Act 2003, CEA (Measure relating to Safety and Electric
Supply), Regulations 2010.
(b) Supply code
(c) State Licensing Board Haryana Rules
(d) National Building Code - Electrical
(e) Electrical Inspectorate standards
(f) Standards published by Central Board of Irrigation & Power
(g) Safety Manual
(h) All important BIS specifications as directed
by the Licensing Board and the Electrical Inspectorate from time to
time.

15. Major works carried out in Haryana

(List be attached with details of installation, scheme approval obtained from Electrical Inspectorate,
etc)
16. Details of punishment and penalty imposed on the company/firm.
1) By State Licensing Board, Haryana.
2) By Government & Other agencies.
3) Any Court of Law.
17. Applied for which tehsil. _________________
 Declaration
 I/we have read and understood the conditions and documents required to be attached
with application for grant of Electrical Contractor Licence Class ‘A’ and relevant
documents are attached in chronological order.
 I/we hereby declare that the staff specified in column 13 is intended exclusively for
attending to the work under the Licensing Board Rules and under regulation 29 of
“Central Electricity Authority (Measures relating to Safety and Electric Supply)
Regulations 2010”. The service of the staff will not be utilized for routine operations
in the establishment nor they will be mixed up with the staff employed under
regulation 3 and 5 of the CEA Regulations, 2010.
 I/we hereby declare that I/we have in my/ our possession a copy of the Electricity
Act 2003, CEA regulations 2010 as well as relevant codes of Practice and Standards
of Indian Standards Institution relating to Electrical Installations. I/We fully
understand the terms and conditions under which an electrical contractor licence is
granted, a breach of which will render the licence liable to cancellation.
 I/We hereby also agree to maintain such registers and records as may be prescribed
by the Board in the forms specified for the purpose.
 I/we do solemnly affirm and declare that the facts submitted in the application are
true and correct to the best of my knowledge and nothing has been concealed by
me/us.
 I am authorized to sign this application as individual/on behalf of the firm.
 I/we are fully aware that this self declaration has the same validity as duly sworn
statement of fact in a court of law and any false information provided by me through
this application shall be liable for punishment under the relevant sections of the India
Penal Code 1860.

Signatures

Address
Place:
Dated:-
Conditions and documents required to be attached with application for the Grant of
Contractor Licence Class ‘A’

(a) Class ‘A’ Contractor Licence shall be granted only to a person or a firm having a registered
office in Haryana, U T Chandigarh or NCT Delhi unless exempted from this requirement by the
Board.
(b) Fees
Fees of Rs 2305/- should be deposited in any of the Haryana Treasury under the Head of account
:- “0043-Taxes and Duties on Electricity –Other receipts” and original treasury challan be
attached with the form.
(c) Nature of work
The Class ‘A’ Contractor can carry out erection and installation of all types of electrical
installation works as specified in the licence.
(d ) Establishment
The applicant shall employ solely for the purpose of contract works the minimum following staff
on full time basis and their consent and declaration in the form Annexure ‘B’ should be attached.
1) One Electrical Supervisor holding competency certificate issued by State Licensing Board
Haryana for respective voltage level for which contractor licence is applied for. For EHT level
licence, two electrical supervisors shall be employed.
2) One wireman for licence upto Medium Voltage, two wireman for licence upto HT level and three
wireman for licence upto EHT level shall be employed.
(e) Following Instruments are to be procured and they should be ISI marked /equivalent quality and
test certificates to be furnished at the time of testing of the instruments.
1. Insulation Meggar 500V; 0-50 Mega 
2. Earth Tester with testing kit 0-5 with expanded scale of 1
3. Two nos. Neon Tester.
4. Frequency Meter 45 to 55 Hz
5. Tong Tester 0-800 A (with selector switch to measure different ranges from 10 A
onwards
6. Multimeter (Digital Type) AC/DC
7. 2 pairs of Rubber hand gloves for electrical purposes.
8. 2 Nos. Insulated pliers.
9. All wiring tools and any other instruments which may be considered necessary by the
Board.
The instruments shall be got tested at the Testing Laboratory attached to the Electrical
Inspectorate, Haryana Chandigarh or such laboratory specified by the Board initially
before the issue of licence and thereafter at specified intervals and the test report to be
produced to the Licensing Board for perusal and return.
Other Tools & Plants to be procured and maintained for HT /EHT Contactor Licence.
(i) Insulation Meggar 5000 V; 5000 Mega 
(motorized /electronic type)
(ii) Phase Sequence Tester.
(iii) Spanner set
(a) Double end
(b) Box
(c ) Ring
( d) Adjustable type
(iv) Allen key set
(v) Cutting pliers (Insulated)
(vi) Micrometer/screw gauge
(vii) Nose pliers
(viii) Measuring tapes:
(a) 15 M
(b) 50 M
(ix) Portable compressor with spray gun
(x) Blower
(xi) Screw drivers of all sizes
(xii) Portable welding set
(xiii) Crimping tools with dye set
(a) Hand operated
(b) Hydraulic
(xiv) Rollers for cable laying
(xv) Portable grinder
(xvi) Safety belts
(xvii) Rubber gloves (electrical grade)
(xviii) Portable drill:
(a) Heavy duty
(b) Light duty
 (xix) Tools for pipe threading & jointing
(xx) Chipping tools, chisels etc.
(xxi) Cable jointing facilities
(xxii) Fabrication and material handling facility.

The following additional facilities also have to be provided for EHT Contractor Licence:
1 Digital Earth Clamp Tester 0.01 to 50 with
selector switch.

2 Portable P. F. Meter 5A, 240 V AC

3 Facility for handling heavy machineries

4 Oil filtering and testing facilities

5 Relay testing kit
6 High Voltage Testing facilities

(f) The applicant should have adequate drawing office facilities for the preparation of drawings, blue
prints etc. Also applicant should have library facility.
(g) Production units or manufacturing concerns should segregate the staff employed for the purpose of
contractors licence from the staff engaged for routine operations of the factories. The staff employed
under the Licensing Board Rules and under Regulation 3 & 5 of the “Central Electricity Authority
(Measures relating to Safety and Electric Supply) Regulations 2010”shall not on any account be mixed
up. Failure to keep separate staff for the purpose of the Licensing Board Rules and regulation 29 of CEA,
Regulations, 2010 shall be deemed to constitute violation of the rules and shall render the licence liable
for cancellation .
(h) Declaration to the effect that “ my/our firm/company has never been blacklisted by any Govt. /Semi
Govt. Organization and nor any such licence issued previously in my name or in the name of any relative
/spouse has been cancelled for any breach or infringement of conditions of the Licence” should be
attached.
(i) The age of prospective applicant for Contractor Licence should be minimum 21 years of individual
in case of proprietary firm and of authorized signatory in case of firm/company.
(j) Proof of residence to be enclosed.
(k) The application for Contractor Licence shall be accompanied with income return/balance sheet for the
last three years. The eligibility for issue of license for various categories will be as under:-
 i) Upto MV (650 Volts) minimum Rs.15 lac turnover in one year during last three
years.
ii) Upto HV- minimum Rs 50 lac turnover in one year during last three years.
iii) Upto EHV minimum Rs. One Crore turnover in one year during last three years.
(l) The applicant will be required to submit PAN Number, service tax and sales tax number as
applicable.
(m) The applicant will present himself for pre-screening alongwith above documents, his appointed
supervisor and wireman in person with instruments.
 Annexure-B
Form of Declaration

I________________________ hereby declare that I am willing to work/ working under

Ms./Shri/M/s ________________________________as full time employee. My Supervisor’s
/Wiremen’s Permit Number is __________________________ . It is valid upto
__________________.
2. I am at present employed under Ms./Shri/M/s ____________________ I have already given
notice/will give notice to her/him/them of my intention to leave the service under
her/him/them (vide letter dated _________)
3. I shall intimate the Licensing Board as well as ______________________ under whom I am
working at present in the event of any change in my employment.
4. I also hereby affirm that I shall
abide by the provisions of the Electricity Act and Regulations as well as of the State
Licensing Board Haryana Rules and with all circulars/instructions which are issued by the
State Licensing Board and the Electrical Inspectorate in all respects.

Place:
Date:
Name and Signature of Supervisor/Wireman.
 Appendix –II
Application for Duplicate Licence/ Competency Certificate / Permit

I hereby apply for the issue of duplicate of my Licence /Certificate / Permit which is attached vide details
given below:

1 (a) Name of the applicant

as in the Licence /Certificate / Permit
(b) Age and date of birth
(c) The date on which the applicant completes 55
years
2 Address with Pin Code

3 Document of which duplicate is required i.e.

Licence /Certificate / Permit
(No. & date of the document should be specified)
4 Date of expiry for licences, Certificates and
permits only
5 Whether the document is lost, defaced, mutilated,
destroyed or damaged
6 When was it destroyed or lost and whether any
proof for destruction or loss is available
7 Details of the defaced, mutilated or damaged
document enclosed
8 Details of fees paid
Name of treasury Number and Date of the challan Amount

9 Details of documents enclosed

1
2
3
4
5
 Declaration
I ……………………………solemnly declare that the above particulars are correct. My Licence /
Competency Certificate / Permit No …………… dated ……………. is lost irrecoverable/destroyed/
defaced/damaged /mutilated. I further declare that in case the original of the document is received or
traced out later, I shall return it to the Secretary, State Licensing Board, Haryana.
I am authorized to sign this application as individual / on behalf of the firm.

Place:
Date:
Signature of the Applicant
 Appendix –III
Application for renewal of Electrical Contractor Licence

I hereby apply for the renewal of my licence which is attached (vide details given below)

1 Name of the applicant

(as in the licence )
2 Address with Pin Code

3 Document to be renewed Electrical Contractor

License Class A .

4 Number of the Electrical Contractor Licence.

5 Date of expiry of the licence.
6 Whether the application for renewal is belated.
If so, the period (in months) by which the renewal
is late
7 Details of fees remitted
8 Name of Treasury

a) Number and date of challan

b) Amount remitted

9 Whether there is any change of address? if so,

mention new address.

a) Present address

b) Whether the address has to be changed in

the Licence also?

10 Whether the equipments have been tested as required in the SLB Haryana Rules. Certificates
be attached
 11 Details of staff as on the date of application (Supervisors and Wiremen)
Name Certificate/Permit Number Date upto which valid

12 Whether there was any change in the staff ? If so,

date of intimation to SLB be specified)

Declaration
1. Information furnished in the application is correct.
2. I/We am /are maintaining all the registers and books prescribed in the SLB Haryana rules and in
the circulars/letters issued by the SLB Haryana.
3. I am authorized to sign the application as contractor /on behalf of the contractor.

Place:
Date:
Signature of the Applicant
 Appendix –IV
Application for Renewal of Supervisor Competency Certificate and Wireman Permit
I hereby apply for the renewal of my competency certificate / permit which is attached (vide
details given below)
1 a) Name of the applicant
(as in the Competency Certificate/permit )
b) Age and date of birth
c) The date on which the applicant completes 55
years. (Attach medical fitness certificate in case
age is above 55 years).
2 Address with Pin Code

3 Supervisor competency certificate No.

Wireman Permit No.
4 Date of expiry of the permit /SCC.
5 Whether the application for renewal is belated.
If so, the period (in months) by which the renewal is
late.
6 Details of fees remitted
Name of Treasury
Number and date of Challan

Amount remitted

7 Name and address of the employer, if any.

If the employer is a contractor, his License Number
should be quoted
8 Whether there is any change of employer
during the period subsequent to the last renewal

9 Whether there is any change of address, if so mention

new address.

I solemnly declare that the information above are correct.

Place:
Date:
Signature
 Appendix V
Application for upgradation of Supervisor Certificate
1 Name
2 Address with Pin Code

3 Qualification
(a) Academic
(b) Professional
4 Details of the Supervisor competency certificate now possessed by the applicant
SCC No
Date of issue
Present scope
5 Experience

Name of Description of the post held by the From To

employer applicant

Total Period of Years Months

experience

6 Whether applied for upgradation earlier ? if so, mention date on

which called for interview?
7 Scope voltage level applied for ?
Place
Dated
Signature of applicant
Note:
1 No application for up gradation will be entertained within a period of one year from the date of issue of the
Supervisor Competency Certificate / date of last interview for up gradation.
2 One self addressed stamped envelope worth of Rs 35/- should be enclosed.
 (Form-A-1)
APPLICATION FORMAT FOR THE INSPECTION OF EHV ELECTRICAL
INSTALLATIONS (OTHER THAN OVERHEAD TRANSMISSION LINES)

(Note: Please read the Procedure/Instructions before filling the Form and write/tick the relevant).

Sub Centre: HO Chandigarh/ Panipat /Gurgaon/Faridabad /Hisar.

1 Name of Installation(s) (type and brief detail)
2 Applicant
a Name of owner of Organization & Address
b Name and Address of responsible Supervisory
Officer (indicating Phone/Mobile/e-mail/Fax )

3 Fault Level (Short Circuit) of installation

4 Interrupting Capacity of Circuit Breaker (s)
5 Minimum ground clearance of the bare conductor
6 Whether all the relevant provisions of the Central
Electricity Authority (Measures relating to Safety
and Electric Supply) Regulations, 2010 have
been duly complied with?
(as stated in chapter III to VI)
7 Whether the installations are placed in position,
properly jointed, duly completed and is (are)
ready for energisation
Attach Completion Certificate & Test Report
and indicate the tentative date(s) of installation to
be inspected
8 Enclosures:
(Please tick the relevant block, if applicable and
enclosed
a Drawings showing the location, layout, elevation
and section
b Single Line Diagram with metering & protection
 c List of Equipment offered for inspection
(Name, Make , Sr. No, Capacity)
d Site Test results ( Equipment wise)
i) Insulation Resistance test
ii) Earth Resistance of individual electrodes,
combined electrodes and earth mat
(iii) High voltage test
(iv) Polarity test
(v) Primary injection test
(vi) Secondary injection and protection trip test
(vii) Relay calibration test
(viii) Annunciation test
(ix) Function, sequence and interlock test
(x) Dielectric test (BDV) of Oil
(xi) OCC/SCC tests of Generator
(xii) Excitation System and AVR tests
(xiii) Protection Stability and Direction test
(xiv) Voltage Ratio and Vector group test
e Manufacturer’s Routine Test Certificate for each
equipment and cables
f Copy of Contractor’s License

It is certified that the installation mentioned above has been checked by me/Competent Authority and
the work has been executed according to CEA (Measures relating to Safety & Electric Supply)
Regulations, 2010 under the supervision of competent Electrical Supervisors and is now complete in
all respects.

Signature of Licensed Electrical Contractor

Licence No..................................................
Date.......................................................................

Signature of owner/XEN/SDO/Authorised
Engineer-Incharge
Designation .................................................
Address..........................................................
Date................................................................
 (Form - A-2)
APPLICATION FORMAT FOR THE INSPECTION OF H.T. (UPTO 33KV) INSTALLATION
BY THE O/O CHIEF ELECTRICAL INSPECTOR TO GOVT., HARYANA.
(Note: Please read the Procedure/Instructions before filling the Form and write/tick the relevant).

Sub Centre: HO Chandigarh/ Panipat /Gurgaon/Faridabad /Hisar.

DETAIL OF THE SUB STATION/GENERATING SET
a Location at which installed
b Voltage ratio/Level
c Capacity of transformer/Generator
d Sanctioned Load/contract demand
e Earth resistance results of Transformer/Generator Pit No. 1 _____ Pit No. 2 _____ Pit No. 3 _____
Pit No.4 _____ Pit No. 5 _____
f Insulation resistance of T/F at ___ ºc HT side R-E = ; Y-E= ; B-E =
g Insulation resistance of T/F at ___ ºc LT side R-E = ; Y-E= ; B-E =
h Dielectric test (BDV) of oil
i Location of the Lightening Arrestor
j Insulation resistance of Generator Set at ___ ºc R-E = ; Y-E= ; B-E =
k Protection scheme provided on the Generator Set
l OCC/SCC tests of Generator.
m Excitation system and AVR tests
n Manufacturer’s routine test certificate of the
equipment
o Name & Designation of responsible Supervisory
Officer
It is certified that the installation mentioned above has been checked by me/Competent Authority and the
work has been executed according to CEA (Measures relating to Safety & Electric Supply) Regulations, 2010
under the supervision of competent Electrical Supervisors and is now complete in all respects.

Signature of Licensed Electrical Contractor

Licence No..................................................
Date.......................................................................

Signature of owner/XEN/SDO/Authorised
Engineer-Incharge
Designation .................................................
Address..........................................................
Date................................................................
 (Form-B-1)
APPLICATION FORMAT FOR THE INSPECTION OF EHV OVERHEAD
TRANSMISSION LINES

(Note: Please read the Procedure/Instructions before filling the Form and write/tick the relevant).

Sub Centre: HO Chandigarh/ Panipat /Gurgaon/Faridabad /Hisar.

1 Name of the Overhead line/Feeder

2 Applicant
a Name of owner of Organization & Address

b Name and Address of responsible Supervisory

Officer (indicating Phone/Mobile/e-mail/Fax )

3 Whether the installation (s) has been completed and is

(are) ready for energisation
Attach completion certificate and indicate the tentative
date of installation to be inspected
4 Route length of the line (KM)

a Single Circuit
b Double Circuit
Total Route length of the line (KM)

5 Size of;
Conductor
Ground Wire

6 Span (meter)

a Average
b Minimum
c Maximum
7 Minimum Clearances (in meter)

a Ground Clearance

i at normal spans
ii at Road crossings
a) National Highway
b) State Highway
 c) Other Roads.
iii At Power lines Crossings
800kV
400kV
220kV
132kV
66kV
33/22kV
11 KV
LT lines

iv At Railway crossing
v At River crossing
vi At Special crossing (if any)
8 Minimum calculated Factor of Safety for conductor
and Towers
9 Whether the followings have been duly provided?

a Tower Anti-Climbing Devices (ACD)

b Danger Notice Board
c Phase indicator plates
d Protection against lightning faults
e Protection against ground faults
f Protection against snapped conductors
g Other protections provided, if any
h Voltage Regulation at the end of the line
10 Whether all relevant provisions of CEA (Measures
relating to Safety and Electric Supply )Regulations,
2010 complied with? (as stated in chapter VII)
11 Name of Sub station/Switching station and Bay Nos.
at which the Overhead Line/Feeder is terminating on
either end.
12 Whether the application for inspection of associated
Substation/Bays has been submitted and
substation/bays are ready for inspection or already
inspected and approval obtained
13 Maximum Height of the Tower

14 Nearest distance of the Line from the nearest airport

15 a Enclosures:
(Please tick, if applicable and enclosed or write NA)
i Contractor’s license
b The following No Objection Certificates/Clearances
from the concerned Authorities shall be enclosed.
Wherever not applicable an undertaking of the same
by the Owner of the line shall be submitted
i Railway Authorities for Railway line Crossings

ii Air Port Authorities /Civil Aviation

iii Air Headquarters /Defence Authorities

iv Approval of PTCC

v SEB for Power line Crossing

vi Forest Clearance

vii Navigation Authorities

viii National Highway Authorities

ix Any other Authority

c Drawing showing Route of Transmission Line on
State map in case of EHV Lines
d Tests results of Earth Footing Resistance of Each
Tower
e Line schedule giving details of Tower type, Angle of
deviation, span length and important features such as
Road (NH/SH/Other), Telegraph line, River, Canal ,
Railway or Power line
f Copy of Maufacturer’s Tests Certificates in respect of
Conductor, Ground Wire, Disc Insulators, Towers
(Proto/Destructive) and Hardware fittings
g Drawings for Anti-Climbing Devices, Danger Notice
Boards Number Plates, Phase plates, Circuit Plates,
Bird guards, Earthing System
 h Details of Crossings (ref. Sl. No. 7)

Sl Type of crossing Nos. Tower Approached from

Locations
No.

It is certified that the installation mentioned above has been checked by me/Competent Authority and
the work has been executed according to CEA (Measures relating to Safety & Electric Supply)
Regulations, 2010 under the supervision of competent Electrical Supervisors and is now complete in
all respects.

Signature of Licensed Electrical Contractor

Licence No..................................................
Date.......................................................................

Signature of owner/XEN/SDO/Authorised
Engineer-Incharge of Line
Designation .................................................
Address..........................................................
Date................................................................
 (Form - B-2)
APPLICATION FORMAT FOR THE INSPECTION OF H.T. (UPTO 33KV) LINE BY THE
O/O CHIEF ELECTRICAL INSPECTOR TO GOVT., HARYANA.
(Note: Please read the Procedure/Instructions before filling the Form and write/tick the relevant).

Sub Centre: HO Chandigarh/ Panipat /Gurgaon/Faridabad /Hisar.

DETAIL OF THE LINE

a Name of the line/ feeder
b Voltage of the line
c Single circuit/ Double circuit
d Route length of the line (KM)
e Size of the conductor
f Size of the ground wire
g Size of underground cable/ AB cable
h No. of railway crossing
i No. of highway crossing
j No. of crossing with Power lines
k Name & Designation of responsible
Supervisory Officer

It is certified that :-
 The Line has been provided continuous earth wire till tail end and has been earthed properly.
 The clearance (Horizontal/ Vertical) of the lines with other HT/LT lines and with the buildings has been
maintained as per CEA Regulations, 2010.
 The guarding has been provided at the crossing points of line, river, road and special crossing (if any).
 The installation mentioned above has been checked by me/Competent Authority and the work has been
executed according to CEA (Measures relating to Safety & Electric Supply) Regulations, 2010 under the
supervision of competent Electrical Supervisors and is now complete in all respects.

Signature of Licensed Electrical Contractor

Licence No..................................................
Date.......................................................................

Signature of owner/XEN/SDO/Authorised
Engineer-Incharge of Line
Designation .................................................
Address..........................................................
Date................................................................
 (Form-C-1)
(Application format for Periodical Inspection of the Electrical installation)

1. Name of Installation :
(type and brief details)

2. Applicant:

(a) Name of owner of Organization & Address :

(b) Name and Address of Concerned Officer :

(indicating Phone/Mobile/e-mail/Fax)

3. Whether all relevant provisions of CEA (Measures relating to : Yes/No

Safety and Electric Supply) Regulations, 2010 have been
complied with? (as stated in chapter III to VI or in chapter VII
in case of O/H lines)

4. Dates of last statutory inspection

(a) Regulation 43/32 :

(b) Regulation 30 :

5. Whether all the observations/non-compliance raised in

last inspection have been duly complied with ? : Yes /No

6. Enclosures;
(Please tick, if enclosed)

(a) List of equipment (s) offered for inspection

(name, make, Sr.No., capacity) :

Signature of owner/Incharge of installation………………………

 FORM A
[see rule 4(1)]
NOTICE INTIMATING THE COMPLETION OF THE WORK OF ERECTION OF A
LIFT AND APPLICATION FOR REGISTRATION TO WORK THE LIFT.

To

The Inspector of Lifts,

....................................

Subject: Erection of the Lift at the .............................................................

Sir,

I/ We have to state that the work of erection of the lift at the above mentioned
premises has been completed on
..........................by/through.......................................................................... I/we further request
that it may be registered and permission for working may be granted. The work of erection of the
lift has been carried out in accordance with the provisions of the Haryana Lifts and Escalators
Act, 2008(27 of 2008).

A fee of Rs. 2,500/- ( Rupees Two Thousand Five Hundred only) for each lift has
been deposited into the Government Treasury and the Treasury receipt in original for that
amount is enclosed.

A work completion report of the manufacture of lift or Company of Electrical and

Mechanical Engineers, completion report of the licensed Electrical Contractor and a copy of
annual insurance policy covering insurance for the passengers using the lift, annual maintenance
contract and safety certificate taken by the owner of the lift are enclosed.

Yours faithfully,

Signature of the owner.

Date:
Encl. 1. Challan of Government Treasury.
2. Work completion report of the manufacturer of lift or company of Electrical and
Mechanical Engineers.
3. Work completion report of the Electrical Contractor.
4. Copy of annual Insurance Policy.
5. Copy of annual maintenance contract.
6. Copy of safety certificate.
 FORM B
[See rule 4(1) (a)]

To

The Inspector of Lifts,

....................................

Subject: Erection of lift at .....................................Submission of Completion Report.

Sir,

We................................................................................................................(Name
of the manufacturer of lifts or Company of Electrical and Mechanical Engineers,) having
undertaken the work of erection of the lift at the premises of
................................................................................................................................and having
completed the erection of the said lift hereby certify that the work of erection of the lift complies
with the provision of the Haryana Lifts and Escalators Act, 2008 (27 of 2008). We further certify
that the erection and testing of the lift has been carried out in accordance with the Haryana Lifts
and Escalators Rules, 2008 and confirm that the lift, car, motor, controller, ropes, governor and
all system have been tested and confirm to the Bureau of Indian Standards.

It is certified that the building in which the lift is erected is structurally sound and stable.

We further certify that the lift installation is ready for inspection which is required to be
made for the purpose of registration under said Act and rules for working the same.

The particulars of the lift are as under:-

1 Make of lift and serial number.

2. Type of lift.
3. Type of control.
4. Capacity.

We undertake the full responsibility of the installation to be handed over duly to the
owner after inspection and compliance of provisions of the said Act and rules.

Yours faithfully,

Signature of the Manufacturer of lifts or the

Date: Company of the Electrical and Mechanical Engineers.
 FORM C
[see rule 4(1) (b)]
FORM OF COMPLETION REPORT FROM LICENSED CONTRACTOR FOR
ELECRICAL WORKS OF LIFT.

To

The Inspector of Lifts,

...................................

We report that the electrical installation detailed below has been installed by us and
tested and that to the best of our knowledge and belief it complies with Indian Electricity Rules,
1956 as well as the Indian Standard Code of practice for Electrical Installations:-

(1) Electrical Installation at:

(2) Voltage and system of supply:
(3) Particulars of works—
(a) M.V. Installation :

No. Equipment Capacity Voltage Fed from Distribution board/

Switch Board.
(b) Lighting:
N.B.- Additional sheets to be used, if needed, for furnishing details against any items.
( c ) Test results-

I (1) Insulation Resistance for the whole installation.

(2) Between phases.
(3) Between each phase and earth.

II (1) Resistance of each electrode for earthing system.

(2) Maximum earthing resistance of installation.

........................................................ ................................................................
Signature of Supervisor, Signature of Electrical Contractor
Name and address. Name and Address.

......................................................... ..................................................................

Competency Certificate Electrical Contractor’s Licence

No................................................... No.............................................................
Valid upto........................................ Valid upto.................................................

Dated...............................................
 FORM E
(See rule 6 )
Application for registration for working a lift erected prior to the commencement of the
Haryana Lifts and Escalators Act, 2008.

To
The Inspector of Lifts,
..................................

1. Full name and address of the applicant:

2. Name and address of the local agent, if any :

3. Address of the place where the Lift has been

erected together with the name of owner thereof:

4. Date of erection :

5. Type of Lift erected :

6. (i) Maker’s Name :

(ii) Maker’s local agents, address :

7. The contract speed of the Lift :

8. The contract load of the Lift (in Kgm.) :

9. The maximum number of persons including

the Lift attendant which the Lift can carry :

10. The total weight of the Lift Car including

the contract load :

11. The weight of the counter weight :

12. The number, description, weight and size

of the suspension ropes :

13. The pit depth :

14. Travel and the number of floors served :

15. The total head room :

16. Details of construction of the over head
arrangement with the weight and size of the
beams :

17. Whether a fee of Rs. 1000/- (One thousand

rupees only ) each lift has been deposited into
the Government Treasury and challan enclosed :

Date Signature of the Owner of the Lift.

Encl: 1. Copy of annual Insurance Policy taken by the owner of the Lift covering insurance for
the persons using the Lift.
2. Challan of Government Treasury.
3. Annual maintenance contract.
4. Safety certificate.