Appendix C - Construction Impact Notification.pdf

Directorate of Public Works Detroit Arsenal

APPENDIX C

Appendix C - Construction Impact Notification (11-Dec-2023) a [lilf:l;Mi]

Form: CIN Last Revision: 11 December 2023

Construction Impact Notification Form US Army Garrison - Detroit Arsenal

Directorate of Public Works This information is required 14 days in advance for notification of all construction activities and must be submitted in electronic format. Drawings must be attached showing location and impact. This may be submitted in conjunction with an excavation permit application. The responsible USAG DPW POC for coordination of this document at the Detroit Arsenal, MI, is Brent Atkinson (586) 282-5262.

• Project Name: ______________________________

• Contract No.: ______________________________

• Contractor Name: ____________________________

• POC Name & Phone No. ________________________

• Date Submitted: Click or tap to enter a date.

1. Describe Work Being Performed that is causing the impact:

2. What will be impacted? Provide a short summary and describe any mitigating being taken.

Check the below boxes as applicable.

IMPACT SUMMARY:

☐ Electrical Substation ☐ Lighting ☐ Water ☐ Telecom ☐ Compressed Air ☐ Loss of heat ☐ Loss of cooling ☐ Fire Alarm ☐ Fire Suppression ☐ Mass Notification ☐ Vehicular Traffic ☐ Parking ☐ Pedestrian Traffic ☐ Other: ________

3. Describe/show the Exact Location (including limits of construction – show in attached map):

4. Schedule:

Start Date (indicate time if less than full day): ________________ End Date (indicate time if less than full day): _________________ Any dates omitted? (I.e., weekends): _________________

5. Describe work activities during after-hours or weekend work: _________________

6. Describe any special needs, requests, coordination, or support required: ____________

7. Any additional comments? _________________