Appendix E - DTA-F-004-24_ClearancePermitRequest-v1.1 (new).pdf
PDF 1 MB Posted
- Attached to
- R/R Diesel Tank
- Solicitation number
- AEW-0170-0553
- Issued by
- Macomb County, Westland City, Michigan
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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:
6.4.0.20180228.1.932123.929382
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