9. Utility and Service Impact Permit Form (USIP 600-148-R2)-07.10.2020.pdf

VA Long Beach Healthcare System Tibor Rubin Medical Center

Form USIP 600-138-R2

Date:

GC Safety Manager:

Phone:

Start Date: Start Time:

End Date: End Time:

Oxygen Nitrous Oxide Air Vacuum

Feeder Panel (#_____) Riser Circuit (#_____)

Air Handler Exhaust Fan

Water Steam Natural Gas

Hot Water Cold Water Heating Sewer

Device Type: Device Identifier:

Sprinkler Fire Pump Jockey Pump

Smoke Heat Pull AV

Date:

Phone:

Narrative to include sequence to make utility safe and then bring back on line; SOP may be attached in lieu of a description.

Section C - Shutdown Process

Work order(s) placed. WO #'s_______________________________________________________

UTILITY AND SERVICE IMPACT PERMIT

Fire Suppression:

Initiating Device:

Other:

Prime Contractor:

Contractor POC:

HVAC:

PART I (Filled out by Contractor or Requestor)

Section A - Requestor Information

Section A - COR/PM Information

Medical Gas:

Electrical:

Section C - Systems

Plumbing:

Fire Alarm:

Section D - Purpose of Shutdown

PART II (Filled out by COR, Supervisor, or PM in coordination with Engineering M&O and Safety)

Section B - Areas Effected by Shutdown

List the rooms effected by the shutdown (Highlight rooms that contain Critical Mission equipment or functions)

Section B - Date and Time of Impact (21 day notice required)

Describe the purpose of the utility and/or system impact.

VA COR/PM:

When impacting fire alarm system utilize Worksheet A if shutdown effects only an individual device or system reset to restore to normal. Complete Parts II and III of this form if multiple devices or entire fire zone is affected.

Project #

Plant:

Map of impacted areas and control shutoff points included with this form

Utility and Service Impact Permit 1 of 2

Form USIP 600-138-R2

UTILITY AND SERVICE IMPACT PERMIT

Lockout: Simple Complex Form Attached (Complex Only) _____N/A

Electric "Live Work": Yes No Form Attached

Hot Taps:

Hot Work Permit: Yes No Form Attached

Hazard Assessment: Yes No Form Attached

ILSM: Yes No Form Attached

VISN Notification: Yes No Form Attached

ICRA: Yes No Form Attached

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

Service POC :__________________________ Title: ________________ Signature:____________________________

COR/Supervisor/PM : Signature: Date:

Shop Requiring Shutdown: __________________. Supervisor approval below:

Print name: Signature: Date:

Shop Requiring Shutdown: __________________. Supervisor approval below:

Print name: Signature: Date:

Shop Requiring Shutdown: __________________. Supervisor approval below:

Print name: Signature: Date:

OSEMS Safety Manager: Signature: Date:

General Foreman: Signature: Date:

Owning Section Chief: Recommendation: Approval Disapproval

Signature: Date:

Chief, Engineering Service: Date:

Section D - Special Issues Required (Forms highlighted below need to be posted in the jobsite)

NOT AUTHORIZED

Section B - Notification of Employees

Section A - Approvals

PART III (Routed to Signatures per Section A)

Date: ______________

Date: ______________

Date: ______________

Date: ______________

Date: ______________

PART II Cont'd (Filled out by COR, Supervisor, or PM in coordination with Engineering M&O and Safety)

Affected employees shall be notified both before the onset of and after completion of the outage.

Construction Safety Committee Notified - Email: VHALONCSCNotifications@va.gov

General Notification (3 Days Out) - On schedule -Email: VHALONENGINEERINGACTIONITEM@va.gov

Section E - Service representative concurrence (Service POC will print name, job title, sign, and date)

Date: ______________

Date: ______________

Date: ______________

Date: ______________

Date: ______________

Date: ______________

Date: ______________

Date: ______________

Utility and Service Impact Permit 2 of 2

Form USIP 600-138-R2 Worksheet A

General Notes:

2. VA Facilitates all programing.

What type of device Fire Alarm: Device Type: Device Identifier:

Fire Suppression: Sprinkler Fire Pump Jockey Pump

Initiating Device: Smoke Heat Pull/AV

Electronics Contractor

Safety Office Other: .

Has Safety Service been informed? YES NO N/A

Describe the work that is being conducted:

Describe how this work will impact the fire alarm system:

Describe how long the fire alarm system will be affected- Time/date(s):

Additional Comments:

FIRE ALARM EQUIPMENT STATUS

REPORT OF ACTIONS

Who is putting the fire system into a trouble condition? (Name and Department/Section)

1. Fill out form to ensure an accurate account of the fire system is kept.

3. If fire alarm system is affected for more than 4 hours, ILSM and Fire Watch forms are needed. Final copies must be sent to the VA Electric Shop.

List the areas that will be affected - Building(s), Area(s), Floor(s)+1, etc.:

Worksheet A 1 of 1