Const Auth WO 54431.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: 54431 Project Manager: George G. Ford

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 . . . X( Easement Deed . . . . (

H. Other C. Erosion and Sediment Control

E. Safety Plan . . . . . . . . . X( 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