Appendix E - DTA-F-004-24_ClearancePermitRequest-v1.1 (new).pdf

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DTA-F-004-24

v1.1 of

DETROIT ARSENAL DPW WORK CLEARANCE PERMIT REQUEST

SECTION 1. PERMIT REQUEST (COMPLETED BY REQUESTER/REQUESTING ORGANIZATION)

DESCRIPTION OF PROPOSED WORK AND SCOPE OF EXCAVATION / DATE CLEARANCE NEEDED BY:

SIGNATURE OR REQUESTING OFFICIAL

TELEPHONE NO.

DATE SUBMITTED

Work clearance is requested to proceed with work on Work-Order No. , or Contract No. , involving excavation or utility disturbance per the BELOW sketch. Proposed excavation area of this site been staked or more clearly marked.

TYPE OF FACILITY / WORK INVLOVED

SITE DIAGRAM / SKETCH (attach additional sheets as needed, attach photos of excavation site):

SECTION 2. DIRECTORATE OF PUBLIC WORKS

ORGANIZATION

REMARKS

REVIEWER'S SIGNATURE

A. ELECTRICAL ENGINEER

B. CIVIL ENGINEER

C. ENERGY MANAGER

D. LEAD GENERAL ENGINEER

E. ENVIRONMENTAL DIVISION

SECTION 3. NETWORK ENTERPRISE CENTER (14 Calendar Days to Mark Utilities and Return)

DATE RECEIVED

DATE MARKED

REVIEWER'S SIGNATURE

REVIEWER'S SIGNATURE

DATE MARKED

DATE RECEIVED

SECTION 4. BASE OPERATIONS CONTRACTOR (7 Calendar Days to Mark Utilities and Return)

REVIEWER'S SIGNATURE

MISS DIG: POSITIVE RESPONSE DATE - (Attach screen shot)

DATE CONTACTED MISS DIG/ MISS DIG TICKET NUMBER

SECTION 5. EXCAVATION ORGANIZATION / CONTRACTOR (14 Calendar Days to Submit and Return)

SECTION 6. APPROVAL /DISAPPROVAL

(This section must describe specific precautionary measure to be taken before and during work accomplishment. Reasons for Permit Disapproval shall be identified.)

PERMIT REQUEST IS:

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