[ ] Engineering
WO_______________________ [ ]
Work Request No ___________________
Name of Equipment: ________________________
Description: ________________________________________ Identification:______________________________ __________________________________________________ Location:
__________________________________________________
__________________________________________________ Fed From____________________________ __________________________________________________ Drawing Number:___________________________ __________________________________________________
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ELECTRICAL ENERGY SOURCE HAZARDS FOR THIS PERMIT Check all that apply |
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| [ ] 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 |
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WORK TO BE PERFORMED (outline method):
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| JUSTIFICATION (Reason
for equipment to remain energized, beyond LOTO identification or verification):
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| 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:
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| APPROACH BOUNDARIES
TO LIVE PARTS FOR SHOCK PROTECTION (from NFPA-70E, Table 130.2
(C) |
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| 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* DISTANCE [ ] Not spec’d [ ] 3' 6" [ ] 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.
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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. |
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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 |
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|
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: ______________
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WORKER SUPPORT REQUIRED: [X] Safety Watch Required [ ] Other (describe task): ______________
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| WORK SCHEDULED: Date: Hours: | ||
| Permit expires: Date: Not to exceed one year. |
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| Signatures are
not required until the work briefing is complete |
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| Qualified Person | Qualified Person | Supervisor or Designee |
(performing work): [ ] Safety Watch [ ] Reviewed Hazard Analysis Initials: _______________ [ ] Completed job briefing [ ] Agree to requirements
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(performing work): [ ] Safety Watch [ ] Reviewed Hazard Analysis Initials: _______________ [ ] Completed job briefing [ ] Agree to requirements
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[ ] Prepared Hazard Analysis [ ] Completed job briefing |
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| Name: |
Name: |
Name: |
| Signature: |
Signature: |
Signature: |
| Date: | Date: | Date: |
| AUTHORIZATION FOR MANIPULATIVE ENERGIZED WORK (MODE 3) |
Electrical Safety Engineer
Comments:
Name:___________________
Dept: EH&S
[ ] Reviewed Hazard Analysis [ ] Agree to justification [ ] Agree to analysis
Signature:
_________________________
Date: ____________________
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Responsible Line Manager Requesting Work
Comments:
Name:___________________
Dept: ____________________ [ ] Reviewed Hazard Analysis [ ] Agree to justification [ ] Agree to analysis
Signature:
_________________________
Date: ____________________
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| Division Director Requesting Work
Comments:
Name:___________________
Div:_____________________ [ ] Reviewed Hazard Analysis [ ] Agree to justification [ ] Agree to analysis
Signature:
_________________________
Date: ____________________ |
| Division Director of Employees Performing Work
Comments:
Name:___________________
Div:_____________________ [ ] Reviewed Hazard Analysis [ ] Agree to justification [ ] Agree to analysis
Signature:
_________________________
Date: ____________________ |
|
EH&S Division Director
Comments: Name:___________________
Div:_____________________ [ ] Reviewed Hazard Analysis [ ] Agree to justification [ ] Agree to analysis
Signature:
_________________________
Date: ____________________ |
| Laboratory Deputy Director
Comments:
Name:___________________
Directorate: [ ] Reviewed Hazard Analysis [ ] Agree to justification [ ] Agree to analysis
Signature:
_________________________
Date: ____________________
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