Rev 6-2016
building safety. right at home.
HOMEOWNER VERIFICATION FOR ELECTRICAL WIRING PERMITS
_____________________________________________________, states the following:
(Print Your Full Name On Line Above)
1. I am the owner of the single-family dwelling located on the residential property for which I
am applying for an electrical permit. The complete address of the residence is:
Address:________________________________________________________________
City:_________________________ State:____________ Zip:_____________
2. I live in the single-family dwelling located on the residential property for which I am
applying for an electrical permit, and it will be my principal residence for a minimum
period of two (2) years.
3. I will install and connect the electrical wiring for myself, without compensation or pay
from, or to, any other person.
4. I have sufficient knowledge of National Electrical Code requirements to make an
electrically safe and mechanically secure installation which will meet the minimum
standards of that Code edition referenced in Neb. Rev. Stat. §81-2104.
5. I am aware an inspection is required before any wiring is concealed behind walls, floors,
ceilings, or earth, and a final inspection is required at the completion of the project.
6. I will call the City Electrical Inspector at the above listed phone number to schedule an
inspection. I am also aware that it is not the inspector’s job or duty to be my instructor in
electrical wiring.
7. I am aware that Neb. Rev. Stat. §81-2143 makes it a Class I Misdemeanor for failure to
comply with the terms of this Homeowner Verification.
8. By signing this form, I am stating the above information is true and correct.
_______________________________
Homeowner/Applicant Signature
________________________________
Date
Prevention Bureau
701 Koenigstein Avenue
Norfolk, NE 68701
P402-844-2060 F402-844-2069
www.ci.norfolk.ne.us
Lock Form – warning
this cannot be undone
Planning & Development
Building Services
309 North 5th Street
