PUB-3000, Chapter 8, Appendix A2

Appendix A2. CONTRACTOR ENERGIZED DIAGNOSTICS AND TEST

JOB BRIEFING FORM

[ ] Engineering WO_______________________ [ ] Work Request No ___________________

Name of Equipment: ________________________ Description: ________________________________________

Identification:______________________________ __________________________________________________

Location: _________________________________ __________________________________________________

__________________________________________________

Fed From____________________________ __________________________________________________

Drawing Number:___________________________ __________________________________________________

ELECTRICAL ENERGY SOURCE HAZARDS FOR THIS PERMIT Check all that apply:
[ ] 120-volts	[ ] 277 volts	[ ] Foreign	[ ] Emergency pwr
[ ] 208 volts	[ ] 480 volts	[ ] Remote control	[ ] Less than 50 volts; permit may not be required. See PUB-3000, Chapter 8, Sections 8.7.5 and 8.7.6.
[ ] 240 volts	[ ] Other (describe):	[ ] DC

WORK TO BE PERFORMED (outline method):

JUSTIFICATION (Reason for equipment to remain energized, beyond LOTO identification or verification):

STOP WORK POINTS (If any unexpected energy is found, equipment has been modified since the permit issued, etc):

Description of stop work issue:

NOTE: THIS PERMIT VOID AT ANY STOP WORK POINT!

SPECIAL INSTRUCTIONS:

APPROACH BOUNDARIES TO LIVE PARTS FOR SHOCK PROTECTION (from NFPA-70E, Table 130.2 (C)

SYSTEM VOLTAGE:

[ ] less than 50 volts

[ ] 50 to 300 volts

[ ] 305 to 750

[ ] 751 to 15 kV

[ ] 15.1 kV to 36 kV

LIMITED APPROACH*
(Fixed circuit parts)*

DISTANCE

[ ] Not spec’d

[ ] 3' 6"

[ ] 5' 0"

[ ] 6' 0"

RESTRICTED APPROACH

DISTANCE

[ ] Not spec'd

[ ] Avoid contact

[ ] 1' 0"

[ ] 2' 2"

[ ] 2' 7"

PROHIBITED APPROACH

DISTANCE

[ ] Not spec'd

[ ] Avoid contact

[ ] 0' 1"

[ ] 0' 7"

[ ] 0' 10"

Multiply single phase voltages by 1.73 to obtain correct voltage level to be used (NFPA 70E C.2.11)

* If any conductors moveable, limited approach distance is 10 feet.

FLASH HAZARD ANALYSIS (from NFPA-70E, 130.3 (A))

Fault Clearing Device: (name)_______________ ; (description)_________________

Mfgr’s Model or type number: _____________________

Clearing time, seconds: __________________________

Flash Protection Boundary *

(Check the method used)

[ ] 4.0 feet (systems less than 600 volts, with 0.1-sec clearing time, Ibf < 50 kA, or 5000 A-sec)

[ ] Other;_____________________ please state the source or attach the work performed to derive the boundary.

*Contact the LBNL Electrical Safety Engineer or the LBNL Electrical Safety Committee for assistance

HAZARD/RISK LEVEL DETERMINATION

[ ] Available short circuit fault current less than 10,000 amps? Identify source of calculated value____________

[ ] From NFPA 70E Table 130.7 ( C )(9)(A): __________ [ ] V-rated gloves? [ ] V-rated Tools? Voltage :_____

[ ] Other (describe): __________________

Hazard/Risk Level: [ ] –1 [ ] 0 [ ] 1 [ ] 2 [ ] 2* [ ] 3 [ ] 4

At a distance of_________________________

PERSONAL PROTECTIVE EQUIPMENT
		Cal Rating		Cal Rating
[X] Pants	[ ] FR long sleeve shirt		[ ] FR Flash suit pants
[X] Natural fiber clothing	[ ] FR Pants		[ ] FR Hard hat
[X] Eye protection	[ ] FR Coverall		[ ] FR Safety goggles
[X] Tee shirt (short)	[ ] FR Jacket		[ ] Arc-rated face shield
[ ] Long-sleeve shirt	[ ] FR Flash suit jacket		[ ] Flash suit hood
BARRIERS: [ ] Locked access [ ] Barrier tapes, stanchions [ ] Electrical Hazard signs [ ] Other: ______________			WORKER SUPPORT REQUIRED: [ ] None [ ] Two-person Rule (Ch 8) [ ] Safety Watch (Ch 8) [ ] Other (describe task

WORK SCHEDULED: Date: Hours:
Permit expires: Date: Not to exceed one year.
Signatures are not required until the work briefing is complete.

Qualified Person	Qualified Person	Supervisor or Designee
(performing work): [ ] Safety Watch [ ] Reviewed Hazard Analysis Initials: _______________ [ ] Completed job briefing [ ] Agree to requirements	(performing work): [ ] Safety Watch [ ] Reviewed Hazard Analysis Initials: _______________ [ ] Completed job briefing [ ] Agree to requirements
		[ ] Prepared Hazard Analysis [ ] Completed job briefing
Name:	Name:	Name:
Signature:	Signature:	Signature:
Date:	Date:	Date:

Following Sign off is required prior to scheduled work date:
Work Requested By:	_________________________________________________ LBNL Project Manager or Construction Superintendent (For Scope Of Work)	______________ Date
Reviewed By:	________________________________________________ LBNL Fac. Chief Electrical or Project Electrical Engineer (For NFPA 70 Incident Energy Calculations)	______________ Date
Reviewed By:	_________________________________________________ Plant Operations–Tech. Service Manager or Electric Shop Supervisor (For Notification of Scheduled Work)	_____________ Date
Work scheduled:	_________________________________________________ Date	______________ Time
Following sign off is required prior to start of the specified work on scheduled date.
LBNL Field Person In-Charge	_________________________________________________ LBNL Project Manager or Construction Superintendent (Responsible for Contractor(s), scope of work, PPE and Qualification of Workers)	_____________ Date
Signed By persons responsible for Scope of Work, PPE and Qualifications of the workers Performing the Work:	_________________________________________________ Construction Superintendent (General Contractor)	______________ Date
	_________________________________________________ Person-in-Charge of the work (C10 Licensed Electrical Contractor	______________ Date
	_________________________________________________ 1. Qualified person performing work (Electrician working for C10 Licensed Electrical Contractor)	______________ Date
	_________________________________________________ 2. Qualified person performing work (Electrician working for C10 Licensed Electrical Contractor)	______________ Date

Appendix A2. CONTRACTOR ENERGIZED DIAGNOSTICS AND TEST

(Attachments: Incident Energy Calculations, PPE List per NFPA 70E)