Attachment B VAPHS Hot Work Permit.pdf
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- Solicitation number
- 36C24425Q0714
About this file
This document is a Department of Veterans Affairs Open Flame or Welding Permit form (VA Form 185(200)) that provides detailed safety guidelines and procedural requirements for conducting hot work or welding activities. The form mandates strict safety protocols, including providing fire watch personnel with extinguishers, posting the permit at the work site, notifying government supervisors 48 hours in advance, implementing protective barriers, wearing appropriate protective gear, preventing smoke migration, and ensuring thorough pre-work and post-work inspections. Key safety notes include removing nearby flammable materials, familiarizing workers with fire alarm locations, cleaning up debris daily, and maintaining continuous fire watch until post-work inspection is complete. The form requires signatures from contractor employees, fire watch personnel, and government representatives at various stages of the work process, ensuring comprehensive documentation and safety compliance.
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OPEN FLAME OR WELDING PERMIT
2. LOCATION OF WORK1. NAME OF PROJECT
3. DESCRIPTION OF WORK REQUIRING OPEN FLAME OR WELDING PROCESS
4. TYPE OF PROCESS
5. PROPOSED DATE OF WORK 6. START TIME 7. STOP TIME
SAFETY NOTES
A. Notify Government project supervisor (by submission of this permit) of proposed open flame or welding process schedule a minimum of 48 hours in advance of the first scheduled day of use.
B. Post an approved open flame or welding permit at the work site during all related work.
C. Provide fire watch with extinguisher (more than one may be required).
D. Provide protective barriers and signs to prevent accidental entry by unauthorized personnel.
E. Wear protective clothing and/or gear.
F. Provide protection from falling objects or debris.
G. Prevent migration of smoke and smoldering materials, draw smoke to exterior of building using portable ventilation equipment.
H. When any normally secured exterior door is opened, additional armed guard service is required at the contractors' expense. Request for additional armed guard service must be submitted to Division (00E) by contractor in advance.
I. Remove or protect nearby flammable materials.
J. Become familiar with location of nearest fire alarm pull-stations and additional extinguishers.
K. In the event of a fire, sound the fire alarm and notify guard of location.
L. The fire watch shall remain in the area until completion of the post-work inspection.
M. Clean up all debris, dust, ashes, etc., upon completion of the work each day.
N. Notify Government representative at time of completion of work.
8. FULL LEGAL NAME OF CONTRACTOR EMPLOYEE PERFORMING ACTIVITY
9. SIGNATURE OF CONTRACTOR EMPLOYEE PERFORMING ACTIVITY
11. FULL LEGAL NAME OF PERSON DESIGNATED AS CONTRACTOR FIRE WATCH
12. SIGNATURE OF CONTRACTOR FIRE WATCH
10. DATE
13. DATE
14. SIGNATURE OF GOVERNMENT APPROVING AUTHORITY OFFICIAL
16. SIGNATURE OF GOVERNMENT PRE-WORK INSPECTOR
18. SIGNATURE OF GOVERNMENT POST-WORK INSPECTOR 19. DATE
17. DATE
15. DATE
INSTRUCTIONS: Complete items 1 through 13 of this form for any proposed open flame or welding procedure and submit for approval a minimum of 48 hours in advance of proposed work.
ACKNOWLEDGEMENT: I hereby acknowledge that I have read the above notes and appropriate sections of the project specifications, and that I will comply: (if more than one person will be performing items 8 and 11, provide full legal name, signature, and date of signature for each additional employee on the back of this form.)
FOR GOVERNMENT USE ONLY
DETERMINATION: I have determined that it is not feasible to conduct the above "hot work" in a shop area or outside the building. A permit is issued for the above listed work during the specified dates/times and I have received authorization for a Utility Shutdown for the fire alarm, HVAC, sprinkler, or other systems as required for this work.
CERTIFICATION: I have inspected the work area prior to the specified work and am satisfied suitable precautions have been taken to prevent a fire.
The Fire Watch is knowledgeable in the use of the fire extinguisher provided and how to turn on the fire alarm and/or summon the fire department in the event of an emergency. The building maintenance contractor has been notified of the date, time, and type of work to be performed.
CERTIFICATION: I have inspected the work area not sooner than 30 minutes following completion of the specified work and have found no evidence of hidden fire or smoldering materials. The building maintenance contractor has been notified of completion of this work.
VA FORM
JUN 2000 185(200)
INSTRUCTIONS FOR PERMIT REQUESTER
Item 1 Provide the name and number of the project.
Item 2 Provide the physical location of the proposed work, including room number.
Item 3 Provide a brief description of the activities to be performed and any reason(s) why the proposed work cannot be performed off-site.
Item 4 Check the appropriate block that represents the type of activities to be performed. If type is not listed, check "other" and explain in Box 3.
Item 5 Provide the proposed date(s) for the work to be done.
Item 6 Provide the specific time the activities will begin each day.
Item 7 Provide the estimated time the activities will cease each day.
Item 8 Provide the full legal name(s) of the Contractor's employee(s) who will be performing the work. Required Action: Upon return of approved welding permit from Government representative post permit in sight of work area.
Item 9 Signature(s) of the person(s) listed in Item 8.
Item 10 Date of signature(s) in Item 9.
Item 11 Provide the full legal name(s) of the Contractor's employee(s) who will be acting as Contractor Fire Watch(es) for all activities performed.
Item 12 Signature(s) of the Contractor Fire Watch(es) listed in Item 11.
Item 13 Date of signature(s) in Item 12.
INSTRUCTIONS FOR GOVERNMENT REPRESENTATIVE
Item 14 Signature of Government approving authority. Required Action: Submit Utility Shutdown Request for fire alarm, HVAC, sprinkler, and other systems as required for this work. Receive approval for utility shutdown. Return permit to contractor for posting at work site.
Item 15 Date of signature in Item 14.
Item 16 Signature of Government pre-work inspector. Required Action: Inspect area for potential hazards.
Item 17 Date of signature in Item 16.
Item 18 Signature of Government post-work inspector. Required Action: Inspect area for flame, smoldering debris, or other ignition sources. Submit Utility Shutdown completion notification.
Item 19 Date of signature in Item 18.
BACK OF VA FORM 185(200) JUN 2000
V A LOGO
OPEN FLAME OR WELDING PERMIT
OPEN FLAME OR WELDING PERMIT
2. LOCATION OF WORK
1. NAME OF PROJECT
3. DESCRIPTION OF WORK REQUIRING OPEN FLAME OR WELDING PROCESS
4. TYPE OF PROCESS
5. PROPOSED DATE OF WORK
6. START TIME
7. STOP TIME
SAFETY NOTES
A. Notify Government project supervisor (by submission of this permit) of proposed open flame or welding process schedule a minimum of 48 hours in advance of the first scheduled day of use.
B. Post an approved open flame or welding permit at the work site during all related work.
C. Provide fire watch with extinguisher (more than one may be required).
D. Provide protective barriers and signs to prevent accidental entry by unauthorized personnel.
E. Wear protective clothing and/or gear.
F. Provide protection from falling objects or debris.
G. Prevent migration of smoke and smoldering materials, draw smoke to exterior of building using portable ventilation equipment.
H. When any normally secured exterior door is opened, additional armed guard service is required at the contractors' expense. Request for additional armed guard service must be submitted to Division (00E) by contractor in advance.
I. Remove or protect nearby flammable materials.
J. Become familiar with location of nearest fire alarm pull-stations and additional extinguishers.
K. In the event of a fire, sound the fire alarm and notify guard of location.
L. The fire watch shall remain in the area until completion of the post-work inspection.
M. Clean up all debris, dust, ashes, etc., upon completion of the work each day.
N. Notify Government representative at time of completion of work.
SAFETY NOTES
A. Notify Government project supervisor (by submission of this permit) of proposed open flame or welding process schedule a minimum of 48 hours in advance of the first scheduled day of use.
B. Post an approved open flame or welding permit at the work site during all related work.
C. Provide fire watch with extinguisher (more than one may be required).
D. Provide protective barriers and signs to prevent accidental entry by unauthorized personnel.
E. Wear protective clothing and/or gear.
F. Provide protection from falling objects or debris.
G. Prevent migration of smoke and smoldering materials, draw smoke to exterior of building using portable ventilation equipment.
H. When any normally secured exterior door is opened, additional armed guard service is required at the contractors' expense. Request for additional armed guard service must be submitted to Division (0 0 E) by contractor in advance.
I. Remove or protect nearby flammable materials.
J. Become familiar with location of nearest fire alarm pull-stations and additional extinguishers.
K. In the event of a fire, sound the fire alarm and notify guard of location.
L. The fire watch shall remain in the area until completion of the post-work inspection.
M. Clean up all debris, dust, ashes, etc., upon completion of the work each day.
N. Notify Government representative at time of completion of work.
8. FULL LEGAL NAME OF CONTRACTOR EMPLOYEE PERFORMING ACTIVITY
9. SIGNATURE OF CONTRACTOR EMPLOYEE PERFORMING ACTIVITY
11. FULL LEGAL NAME OF PERSON DESIGNATED AS CONTRACTOR FIRE WATCH
12. SIGNATURE OF CONTRACTOR FIRE WATCH
10. DATE
13. DATE
14. SIGNATURE OF GOVERNMENT APPROVING AUTHORITY OFFICIAL
16. SIGNATURE OF GOVERNMENT PRE-WORK INSPECTOR
18. SIGNATURE OF GOVERNMENT POST-WORK INSPECTOR
19. DATE
17. DATE
15. DATE
INSTRUCTIONS: Complete items 1 through 13 of this form for any proposed open flame or welding procedure and submit for approval a minimum of 48 hours in advance of proposed work.
INSTRUCTIONS: Complete items 1 through 13 of this form for any proposed open flame or welding procedure and submit for approval a minimum of 48 hours in advance of proposed work.
ACKNOWLEDGEMENT: I hereby acknowledge that I have read the above notes and appropriate sections of the project specifications, and that I will comply: (if more than one person will be performing items 8 and 11, provide full legal name, signature, and date of signature for each additional employee on the back of this form.)
ACKNOWLEDGEMENT: I hereby acknowledge that I have read the above notes and appropriate sections of the project specifications, and that I will comply: (if more than one person will be performing items 8 and 11, provide full legal name, signature, and date of signature for each additional employee on the back of this form.)
FOR GOVERNMENT USE ONLY
FOR GOVERNMENT USE ONLY
DETERMINATION: I have determined that it is not feasible to conduct the above "hot work" in a shop area or outside the building. A permit is issued for the above listed work during the specified dates/times and I have received authorization for a Utility Shutdown for the fire alarm, HVAC, sprinkler, or other systems as required for this work.
DETERMINATION: I have determined that it is not feasible to conduct the above "hot work" in a shop area or outside the building. A permit is issued for the above listed work during the specified dates/times and I have received authorization for a Utility Shutdown for the fire alarm, H.V.A.C., sprinkler, or other systems as required for this work.
CERTIFICATION: I have inspected the work area prior to the specified work and am satisfied suitable precautions have been taken to prevent a fire. The Fire Watch is knowledgeable in the use of the fire extinguisher provided and how to turn on the fire alarm and/or summon the fire department in the event of an emergency. The building maintenance contractor has been notified of the date, time, and type of work to be performed.
CERTIFICATION: I have inspected the work area prior to the specified work and am satisfied suitable precautions have been taken to prevent a fire. The Fire Watch is knowledgeable in the use of the fire extinguisher provided and how to turn on the fire alarm and/or summon the fire department in the event of an emergency. The building maintenance contractor has been notified of the date, time, and type of work to be performed.
CERTIFICATION: I have inspected the work area not sooner than 30 minutes following completion of the specified work and have found no evidence of hidden fire or smoldering materials. The building maintenance contractor has been notified of completion of this work.
CERTIFICATION: I have inspected the work area not sooner than 30 minutes following completion of the specified work and have found no evidence of hidden fire or smoldering materials. The building maintenance contractor has been notified of completion of this work.
VA FORM
JUN 2000
V A FORM 1 8 5 (200), JUNE 2000
185(200)
INSTRUCTIONS FOR PERMIT REQUESTER
Item 1 Provide the name and number of the project.
Item 2 Provide the physical location of the proposed work, including room number.
Item 3 Provide a brief description of the activities to be performed and any reason(s) why the proposed work cannot be performed off-site.
Item 4 Check the appropriate block that represents the type of activities to be performed. If type is not listed, check "other" and explain in Box 3.
Item 5 Provide the proposed date(s) for the work to be done.
Item 6 Provide the specific time the activities will begin each day.
Item 7 Provide the estimated time the activities will cease each day.
Item 8 Provide the full legal name(s) of the Contractor's employee(s) who will be performing the work. Required Action: Upon return of approved welding permit from Government representative post permit in sight of work area.
Item 9 Signature(s) of the person(s) listed in Item 8.
Item 10 Date of signature(s) in Item 9.
Item 11 Provide the full legal name(s) of the Contractor's employee(s) who will be acting as Contractor Fire Watch(es) for all activities performed.
Item 12 Signature(s) of the Contractor Fire Watch(es) listed in Item 11.
Item 13 Date of signature(s) in Item 12.
INSTRUCTIONS FOR PERMIT REQUESTER
Item 1 Provide the name and number of the project.
Item 2 Provide the physical location of the proposed work, including room number.
Item 3 Provide a brief description of the activities to be performed and any reason(s) why the proposed work cannot be performed off-site.
Item 4 Check the appropriate block that represents the type of activities to be performed. If type is not listed, check "other" and explain in Box 3.
Item 5 Provide the proposed date(s) for the work to be done.
Item 6 Provide the specific time the activities will begin each day.
Item 7 Provide the estimated time the activities will cease each day.
Item 8 Provide the full legal name(s) of the Contractor's employee(s) who will be performing the work. Required Action: Upon return of approved welding permit from Government representative post permit in sight of work area.
Item 9 Signature(s) of the person(s) listed in Item 8.
Item 10 Date of signature(s) in Item 9.
Item 11 Provide the full legal name(s) of the Contractor's employee(s) who will be acting as Contractor Fire Watch(es) for all activities performed.
Item 12 Signature(s) of the Contractor Fire Watch(es) listed in Item 11.
Item 13 Date of signature(s) in Item 12.
INSTRUCTIONS FOR GOVERNMENT REPRESENTATIVE
Item 14 Signature of Government approving authority. Required Action: Submit Utility Shutdown Request for fire alarm, HVAC, sprinkler, and other systems as required for this work. Receive approval for utility shutdown. Return permit to contractor for posting at work site.
Item 15 Date of signature in Item 14.
Item 16 Signature of Government pre-work inspector. Required Action: Inspect area for potential hazards.
Item 17 Date of signature in Item 16.
Item 18 Signature of Government post-work inspector. Required Action: Inspect area for flame, smoldering debris, or other ignition sources. Submit Utility Shutdown completion notification.
Item 19 Date of signature in Item 18.
INSTRUCTIONS FOR GOVERNMENT REPRESENTATIVE
Item 14 Signature of Government approving authority. Required Action: Submit Utility Shutdown Request for fire alarm, HVAC, sprinkler, and other systems as required for this work. Receive approval for utility shutdown. Return permit to contractor for posting at work site.
Item 15 Date of signature in Item 14.
Item 16 Signature of Government pre-work inspector. Required Action: Inspect area for potential hazards.
Item 17 Date of signature in Item 16.
Item 18 Signature of Government post-work inspector. Required Action: Inspect area for flame, smoldering debris, or other ignition sources. Submit Utility Shutdown completion notification.
Item 19 Date of signature in Item 18.
BACK OF VA FORM 185(200) JUN 2000
BACK OF V A FORM 1 8 5(200) JUNE 2000
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