Fillable North Dakota State Electrical Board Non-GFCI Protected Equipment (North Dakota State Electrical Board)

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North Dakota State Electrical Board Non-GFCI Protected Equipment (North Dakota State Electrical Board)

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North Dakota State Electrical Board
Non-GFCI Protected Equipment Notification
Page: 1 of 1
Installer Information
Full Name:
Date:
Last
First
M.I.
Installing Company’s Name:
Phone:
Email:
Installation Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Permit Number:
Date Installed.:
To date, what has the contractor done to resolve the issue: (Attach a separate sheet if necessary)
Appliance Information
Type of Equipment Installed (Mini Split, Heat Pump, AC or etc.):
Panelboard/ Breaker Information
Panelboard Manufacturer’s Name:
Panelboard Size:
Breaker Manufacturer’s Name:
Breaker Model Number:
Breaker Size:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
Signature:
Date:
Manufacturer’s Name:
Please consider attaching a picture of the nameplate!
* Please complete form and email to electric@nd.gov
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North Dakota State Electrical Board Non-GFCI Protected Equipment (North Dakota State Electrical Board)

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Completed 21 April 2021

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