4. VA Energized Work Permit.pdf

VA LONG BEACH ENERGIZED ELECTRICAL WORK PERMIT

Supervisor, Competent Person, or VA Project Engineer (if no contractor):

Printed Name: Sign:

Work start/stop dates: From: To: Time:

EQUIPMENT NAME, LOCATION AND DESCRIPTION: Work order number:

DESCRIPTION OF WORK TO BE PERFORMED:

JUSTIFICATION FOR ENERGIZED WORK:

ELECTRICAL ENERGY SOURCESPRESENT: Check all that apply:

Maximum Exposure

Minimum PPE level:

RESULTS OF SHOCK AND FLASH ANALYSES: Flash Protection Boundary (2nd degree burn potential):

Approach Boundary (shock protection boundary):

(Note: Employee work on Levels 3 and above is PROHIBITED (work must be contracted) REQUIRED

PERSONAL PROTECTIVE EQUIPMENT:

Non-melting, untreated natural fiber clothing, all layers Shirt (long-sleeve) 8 cal/cm2 Pants (long) 8 cal/cm2 Polycarbonate safety glasses Ear protection EH-rated footwear Insulated tools

Leather gloves Flame-retardant coveralls (Level 1+) 8 cal/cm2

Type 1, Class E hard hat (Levels 1&2) Arc-rated face shield (Levels 1&2) FR flash suit and hood (Level 3+) 40 cal/cm2 Switchboard matting/insulated blankets Other items (specify)

Voltage-rated rubber gloves (Minimum 600V) (Inspect all gloves 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 have 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.

120 Volt 208 Volt

277 Volt 480 Volt

12KV

Generator

[ ] 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 Electric Shop Supervisor Mike Mommerency

Project Engineer

Maintenance Supervisor

John Gorman

Safety Officer

Facility Manager Anthony Streletz

Medical Center Associate Director

Jean Gurga

Work completed date/time: List any unexpected hazards or “STOP WORK” issues encountered: