PUB-3000 Chapter 8 | ELECTRICAL SAFETY | Appendix A: Energized Electrical Work Permit (EEWP)

This permit is required for any activity that is done within the Limited Approach Boundary of exposed energized electrical parts equal to or greater than 50 Volts and 5 milliamps.

Exceptions: Permit is not required for the following activities IF AUTHORIZED IN AN AHD:

i. Testing and Troubleshooting (see Instructions)

ii. Visual inspection only (see Instructions)

LIMITED APPROACH BOUNDARY
VOLTAGE:	DISTANCE
50 to 300	3’ 6”	751 to 15 kV	5’ 0”
301 to 750	3’ 6”	15.1 kV to 36 kV	6’ 0”

PART I – DESCRIPTION OF WORK

(1) Name of Equipment: ________________________ (2) Equipment Description: ______________________________

(3) Other Identification :________________________________________________________________________

(4) Location:__________________________________________________________________________________

(5) Fed From (Panel/circuit)______________________________________________________________________

(6) Drawing Number:___________________________ ______________________________________________

(7) Engineering WO_______________________ (8) Work Request No ___________________

(9) Proposed date of work______________________

(10) DETAILED DESCRIPTION OF WORK TO BE PERFORMED:

(11a) Check If Work Is Testing/Troubleshooting By LBNL Employee, That Is NOT Covered In An AHD And Skip To Line 18

(11b) Check If Work Is Being Done by a Subcontractor or Vendor

(12) JUSTIFICATION of why the circuit/equipment cannot be de-energized or the work deferred until the next scheduled outage (SEE INSTRUCTIONS):

(13) Earliest date that the equipment or circuit can be shut down or next scheduled outage ____________________________________________________________________________

“By signing below, I agree, for the reasons stated above, that it is infeasible to perform this work with the equipment de-energized”
_______________________________________________ (14) Equipment Supervisor (see Instructions) Date	____________________________________________ (15) Deputy Div. Director of Equip. Sup. Date
_______________________________________________ (16) Electrically qualified employee Date	____________________________________________ (16a) Electrically qualified employee Date
____________________________________________ (17) Electrically qualified employee Date	____________________________________________ (17a) Electrically qualified employee Date

Part II - SHOCK HAZARD ANALYSIS (see Instructions)

(18) Exposed
Voltage(s):____________________________________(18a) Locations:____________________________________

(19) Limited Approach Boundary (see Instructions):______________________________

(20) Restricted Approach Boundary (See Instructions):____________________________

(21) Closest distance that worker may come to any exposed live parts (describe)_________________________________________

Part III - FLASH HAZARD ANALYSIS (see Instructions)

(22) [ ] Check this box and skip Part III if the circuit is rated less than 240 volts, supplied by one transformer, AND the transformer is rated less than 125kVA. Flash hazard PPE / Flash Protection Boundary is not required.

Determine Flash Hazard by EITHER 23 or 24,

(23) [ ] Hazard Risk Category and Flash Protection Boundary Labeled.

Enter information from Flash Hazard Label on the equipment or first upstream panel.

Flash Protection Boundary________________________________

Incident Energy (Cal/cm²)________________________________

Hazard / Risk Category [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4

Flash Protection Boundary ________________________________

(24) [ ] Incident Energy and Flash Protection Boundary Calculated.

Engineering Calculation Results:

Flash Protection Boundary________________________________

Incident Energy (Cal/cm²)________________________________

Hazard / Risk Category [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4

Flash Protection Boundary ________________________________

____________________________________________________________________________________

(25) Signature of Engineer Performing Flash Hazard Calculation Date

PART IV - Hazard Controls and Mitigations

(26) How will the shock and flash boundaries be established and maintained?
_________________________________________________________________________________________

(27) List all necessary personal protective equipment to safely perform the assigned tasks:
_________________________________________________________________________________________
_________________________________________________________________________________________

(28) Hazard Class, from PUB 3000, Appendix Q __________ 2 Person Rule? Safety Watch Required?

(29) Identify 2^nd Person or Safety Watch _____________________________________________________

(30) Description of safe work practices and procedures to be employed:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

(31) SPECIAL INSTRUCTIONS, including any Hold Points (see Instructions):

___________________________________________________________________________________

“By signing below, I agree that this energized work can be done safely as described”

_________________________________________ (32) Electrically Qualified Employee Date	_________________________________________________ (33) Electrically Qualified Employee Date
_________________________________________ (34) Electrically Qualified Employee Date	_________________________________________________ (35) Supervisor of Electrically qualified employees Date
______________________________________________________________________________________________ (36) Job Briefing Performed By (Date) (see Instructions) Initials of persons present at briefing

PART V – APPROVALS FOR ENERGIZED WORK

Not Required If 11a is checked

_____________________________________________________
(37) Deputy Division Director of assigned employee(s) Date
(Not Required for Subcontractor)

_________________________________________
(38) EH&S Electrical Safety AHJ Date

FORWARD COMPLETED PERMIT TO ELECTRICAL SAFETY AHJ AT 75B-101