New devices only or combination of new and replacement

Fax: 1-800-667-4278

 esa.Cambridge@electricalsafety.on.ca
Authorized Contractor Program (ACP) SMALL JOBS FORM


Scope of Work for 1:10 / 1:5 / 1:3: 1) Invoice value to customer

OR 2) New devices only or combination of new and replacement (regardless of invoice value)

OR 3) Replacement light fixtures, switches and/or receptacles only (regardless of invoice value)
Commercial/Industrial/Agricultural

Applicant Information		ESA Account Number:      		ECRA/ESA Licence Number:      			Date of Application:      			ACP#:      
Name:      									Telephone:      
Street:      									Fax:      
City:      				Province:      		Postal Code:      			Cell:      
Contact:      									E-mail:      
Site Information Comm  Indust  Agri  Apt 	Site Information Comm  Indust  Agri  Apt 		Site Information Comm  Indust  Agri  Apt 
Name:      	Name:      		Name:      
Civic # & Street:      	Unit #:      		Civic # & Street:      		Unit #:      			Civic # & Street:      			Unit #:      
City / Town:      	City / Town:      		City / Town:      
Twp / Region:     	Twp / Region:     		Twp / Region:     
Site Contact Name:       Daytime Phone #:      	Site Contact Name:       Daytime Phone #:      		Site Contact Name:       Daytime Phone #:      
On-site Location:      	On-site Location:      		On-site Location:      
Date Installation done:      	Inspection Requested *WN RI F		Date Installation done:      		Inspection Requested *WN RI F			Date Installation done:      			Inspection Requested *WN RI F
Installation Value OR Type	Installation Value OR Type		Installation Value OR Type
1 in 10  $750 billed value  OR New devices only, 1 - 10  OR Replacement devices, 1 - 20  1 in 5 $751 - $2,500 billed value  OR New devices only, 11 – 30  OR Replacement devices, 21 - 50  1 in 3 $2,501 - $5,500 billed value  OR New devices only, 31 - 50  OR Replacement devices, 51 - 100 	1 in 10  $750 billed value  OR New devices only, 1 - 10  OR Replacement devices, 1 - 20  1 in 5 $751 - $2,500 billed value  OR New devices only, 11 – 30  OR Replacement devices, 21 - 50  1 in 3 $2,501 - $5,500 billed value  OR New devices only, 31 - 50  OR Replacement devices, 51 - 100 		1 in 10  $750 billed value  OR New devices only, 1 - 10  OR Replacement devices, 1 - 20  1 in 5 $751 - $2,500 billed value  OR New devices only, 11 – 30  OR Replacement devices, 21 - 50  1 in 3 $2,501 - $5,500 billed value  OR New devices only, 31 - 50  OR Replacement devices, 51 - 100 
Work Description:      	Work Description:      		Work Description:      
Existing Hazards on Property Advise local Inspector 	Existing Hazards on Property Advise local Inspector 		Existing Hazards on Property Advise local Inspector 
Comments/Directions:      	Comments/Directions:      		Comments/Directions:      

*WN = Will Notify; RI = Rough-in; F = Final FORM OPS.F1.2.3 (09/16)

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