400 Sheldon Drive, Unit 1
Cambridge, Ontario, N1T 2H9
Phone:
Fax:
1-877-ESA-SAFE (372-7233)
1-800-667-4278
esa.Cambridge@electricalsafety.on.ca

Low Voltage Industrial/Commercial/Institutional/Agricultural Application for Inspection & Fee Estimate
Date:
Acct #:
ECRA/ESA Lic#:
Ready for:
Rough-In
ACP #:
Service
Applicant Information
R/I & Service
Final
Trench only
Grounding only
Disconnect
Will Notify
Date Ready
Name:
Mailing Address:
Unit/Suite:
City:
Prov/State:
Country:
Postal Code:
Phone #:
Fax #:
PO/Job #
Site Information
Commercial
Please indicate:
Industrial
Agricultural
New Residential
Apartment
(>7,000 sq ft, 401+A)
(common or outlying areas)
Name:
Civic #:
Street:
Sub Lot:
Other:
Rural Lot:
Con:
If street is a numbered Regional Road, County Rd, Hwy - note the alternate street name (if appl):
City/Town/PPN:
Twp/RMN
City/Town/Populated Place Name
Township/Regional Municipality Name
Site Contact Name:
Site Contact Ph #:
LV Consumer Service(<=750 Volts) (5.2)
Outlets & Devices (5.7)
(C006, C007, C008)
Amps
Totals sum automatically
based on inputs below
Volt
(C017)
Non-Classified
Qty
Indicate Qty
Amps
Qty
Low Voltage Service Maintenance (C072 / C082)
Amps
Volts Date
ACP Comm Service Work Only 0-225A (C060)
Amps
Volts
Switches
ACP Comm Service Work Only 226-400A (C061)
Amps
Volts
Fire Alarm Devices
Central Metering (C051)
Amps
Qty
(C018)
Indicate Qty
Receptacles
Electronic Metering (e.g. "donuts", check meters)
School Portables (C055)
Classified
TOTALS
**Light Fixtures
Motors <1HP
Permanent Pole Service (C048) Amps
Control Transformers <1KVA
Temporary Services (5.3, 5.2.8)
Generators <5=kW
Temp 1 Phase (C012)
Qty
Amps
Alternators <5=kW
Temp 3 Phase (C016)
Qty
Amps
Heating/Cooking Devices <=5kW
Subdivision (C013)
Magnetic / Kirk locks
# of poles
Construction Trailers (C068)
Streetlights / Parking Lot Lights
Qty
LV ICIA Distribution Equipment (panel, switchboard, splitter, etc) (5.5)
Amps
Bollard Lights
Self-contained Signs
(C019,C020,C021)
Self-contained Fuel Pumps
Qty
Other - describe:
Describe
LV ICIA Miscellaneous Equipment (5.6)
Volts
Power Outlets (>20A or >120V)
(C023)
(C053)
(C054)
**See the Retrofitted Luminaires Application if the work involves changing luminaires from the approved
design by use of approved retrofit kits; or by changing the components to convert them into more
efficient luminaires or into different kinds of luminaires.
HP
KVA
Underground/Overhead Lines (5.4)
Qty
Trench - Primary Line (C050)
Qty
Trench - Secondary Line (C049 / C050)
Qty
Describe
Install branch circuit only for equip [lic] (C071)
Qty
Install equip only no branch circuit [unlic] (C070)
Qty
Transformer Pad Grounding (C052)
Inspected at the same time as other work? Yes
Hrs
Primary/Secondary Lines - # of Poles (C044)
Other Installations (2.8, 5.10.1, 5.11, 6.3, 7.2)
Consultation - Site Visit (MI05)
Hrs
Billboard (C027)
Qty
#m
Payment Method
Qty
New Traffic Signal System (C045)
Qty
Card #:
Solar Panels system >500KW (C081)
Account
Qty
Driving Directions/Main Intersection/Comments/Work Details
Trade Show - # of Booths (C059)
Solar Panels system 10-500KW (C079, 80)
Trolley, Buss Duct,
& Cable Tray (C028)
No
Cheque
KW
MW
Credit Card
Fee Estimate incl HST
Expiry:
Name:
By submitting personal information to the Electrical Safety Authority, or its agents and service providers, you agree that ESA may collect, use and disclose such personal information in accordance with its privacy policy, applicable laws or pursuant
to our administrative agreement with the Province of Ontario. If you provide us with the personal information on behalf of another individual, you represent that you have all necessary authority and/or have obtained all necessary consents from
such individual to enable us to collect, use and disclose such personal information for the purposes set forth in our Privacy Policy. A copy of our policy is located on our website at www.esasafe.com
*See 2016 Electrical Inspection Fee Guide for details
Form 1015LV-A (04/16)
The total cost may change pending a site visit