S06 - Amendment 0008 - ATT 14 - Energized Electrical Work Permit.pdf
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- Attached to
- EHRM Huntington VAMC 581-22-700 Construct Infrastructure Upgrades Federal contract opportunity
- Solicitation number
- 36C77626R0025
About this file
This is an Energized Electrical Work Permit template used to authorize and manage work performed on energized electrical equipment at a facility, likely a Veterans Affairs medical center. The permit establishes safety protocols and hazard controls required when electrical work cannot be postponed until a shutdown period.
The permit requires identification of the supervisor or competent person authorizing the work, work order number, specific dates and times, equipment location and description, and detailed justification for why the work must be performed while energized. It mandates documentation of all electrical energy sources present (ranging from 120 volts to 480 volts and above, including DC and emergency power) and requires completion of shock and flash analyses to determine flash protection boundaries, limited approach boundaries, and maximum exposure levels in calories per square centimeter. Required personal protective equipment is comprehensively listed, including flame-retardant clothing, voltage-rated gloves, hard hats, face shields, and insulated tools, with specific levels mandated based on hazard analysis results. The permit requires barriers and warning signs to prevent unauthorized access to hazard boundaries. Supervisor pre-job briefing must confirm worker qualifications (journeyman electrical rating per 29 CFR 1910.399), safety watch assignment, removal of jewelry and metal apparel, equipment availability and condition, and barrier installation. Multiple approval signatures are required from peer reviewers, project engineers, maintenance supervisors, facility managers, safety officers, and the medical center director. The permit becomes void if unexpected energy sources are discovered or equipment is modified after issuance, and workers must document any stop-work issues encountered during completion.
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Text version
ENERGIZED ELECTRICAL WORK PERMIT
Supervisor, Contractor’s Competent Person, or VA Project Engineer (if no contractor):
Printed Name: Sign:
Work start/stop dates: From: AM To: AM
PM PM
EQUIPMENT NAME, LOCATION AND DESCRIPTION: Work order number:
DESCRIPTION OF WORK TO BE PERFORMED:
JUSTIFICATION FOR ENERGIZED WORK (reason why job can not be postponed until shutdown):
ELECTRICAL ENERGY SOURCES PRESENT:
Check all that apply:
[ ] 120 volts [ ] 277 volts [ ] DC [ ] 208 volts [ ] 480 volts [ ] Emergency power [ ] 240 volts [ ] Other (describe):____________ [ ] <50 volts (permit MAY not be required)
RESULTS OF SHOCK AND FLASH ANALYSES:
Flash Protection Boundary (2nd degree burn potential): _____inches Maximum Exposure: _____cal/ cm2
Limited Approach Boundary (shock protection boundary): _____inches Minimum PPE level: _____
(Note: Employee work on Levels 3 and above is PROHIBITED (work must be contracted) REQUIRED PERSONAL PROTECTIVE EQUIPMENT: Cal/Volt Rating [X] Non-melting, untreated natural fiber clothing, all layers [ ] Voltage-rated rubber gloves (Level 1+) ______ [X] Shirt (long-sleeve) [ ] Flame-retardant coveralls (Level 1+) ______ [X] Pants (long) [ ] Type 1, Class E hard hat (Levels 1&2) ______ [X] Polycarbonate safety glasses [ ] Arc-rated face shield (Levels 1&2) ______ [X] Ear protection [ ] FR flash suit and hood (Level 3+) ______ [X] EH-rated footwear [ ] Switchboard matting/insulated blankets ______ [X] Insulated tools [ ] Other items (specify)________________ ______ [X] Leather gloves (inspect before each use) BARRIERS (to prevent access to flash protection and limited approach boundaries) [ ] Locked access [ ] Electrical hazard signs [ ] Barrier tapes, stanchions [ ] Other (describe):____________________
SUPERVISOR’S PRE-JOB BRIEFING BY: Printed Name: Sign:
Workers are “qualified” (see 29 CFR 1910.399) with a journeyman electrical rating.
Safety watch is required. This person must be “qualified,” able to disconnect all power sources with proper
PPE, and have immediate access to a telephone or radio to summon help in the event of an emergency.
All jewelry and metal apparel has been removed.
Confirmed that insulated tools, EH-rated footwear, switchboard matting, FR-clothing and other equipment is available, in good condition, and appropriate for the hazard level to be encountered.
Verified that barricades and warning signs are installed.
Outlined safe work practices to be followed (document under Special Instructions, below).
STOP WORK POINTS: Permit is void if any unexpected energy is found, or equipment has been modified since the permit was issued.
Special instructions and specific job-related hazards:
QUALIFIED PERSONS that understand and agree to the above plan:
Printed name(s): Signature(s) & Date: Printed name(s): Signature(s) & Date:
SAFETY WATCH:
Printed name: Signature & Date: Printed name: Signature & Date:
APPROVALS Print Sign Date Peer review (2nd qualified person that agrees the work can be safely completed)
Project Engineer Maintenance Supervisor
Facility Manager Safety Officer Medical Center Director
Work completed date/time: List any unexpected hazards or “STOP WORK” issues encountered:
File details come from the government source that posted it. Updated .