construction authorization.doc

Application for Beltsville Agricultural Research Center (BARC)

Construction Authorization Submit Application to:

BARC, Head, Engineering and Construction Branch (ECB)

10300 Baltimore Ave., Bldg. 426A, BARC-East

Beltsville, MD 20705 301-504-8434 Please Allow 5 Business Days for Processing of Application

PART I - Contractor Requirements

(To be completed by ECB Project Manager)

Project Number: 51520 Project Manager: _________Tom Callsen_______________________

The Contractor shall submit the following permits and plans with this Authorization for approval prior to starting work:

A. Open Flame Permit . . . . . . . . . (

D. Revocable Permit/

G. Asbestos Abatement Plan . . . . ( B. Confined Space Entry Plan . . . ( Easement Deed . . . . . . (

H. Other ( C. Erosion and Sediment Control

E. Safety Plan . . . . . . . . . ( Plan/Permit F. Lead Abatement Plan . (

PART II - Contractor Information Start Date: ___________ (To be completed by the Contractor) Date of Application: ________________

Completion Date: ___________ (Refer to instructions on back of application.)

Name of Contractor (Company): Daytime Telephone Number: ________________ Name of Supervisor/Foreman: _____________________________________________

After Hour Emergency Contact: Telephone Number: ___________________ Company(s Mailing Address: ________________________________________________________________

Description of Work to be Performed: _____________________________________________________________________________ __________________________________________________________________________________________________________

Purchase Order/Contract Number:

Location(s) of Work: _______________________________________________ Number of Vehicle Permits Required:

Number of Personnel Identification Badges Required: ____________ What Heavy Equipment is to be used? ____________________________________________________________________________ I have received and read a copy of the BARC Special Conditions and agree to comply with all requirements. Yes ( No ( Applicant(s Signature:

Date: ________________

Print Name:

Title: _______________________________________

PART III - Authorization Approval Application Received By: Date:

Authorization has been:

Authorization Number: __________________ ( Approved

( Approved with the following conditions: _________________________________________________________________________ ___________________________________________________________________________________________________________ ( Disapproved (reason): _______________________________________________________________________________________ ECB(s Authorization Signature: Date:

Print Name: Title: ______________________________ Approved Construction Authorization Must Be:

( In Construction Supervisor(s Possession on the Job Site ( Posted at the Job Site