State of Wisconsin            )
                                        ) ss.
County of                          )

_______________________________________, being duly sworn by oath, says that he is the person who did the following described work of wiring for electricity in the following buildings: owned and occupied by _______________________________________ and located in Section ______________ , Township ______________ , Range ______________ , in the County of ______________________ Wisconsin, and that all of said described electrical wiring at the location above was done so as to comply, and does comply, with the Wisconsin State Electrical Code and the National Electrical Code.

(Signed) _______________________________________