Appendix F - Excavation Permit Form.pdf

FORM PWF-103 REV 09Oct 2014 page 1 of 4

US ARMY GARRISON- DETROIT ARSENAL (USG-DTA)

DPW-ENGINEERING DIVISION

DETROIT ARSENAL BASE EXCAVATION PERMIT

(See attached instructions )

Date Permit Submitted Date Permit Received Permit No.

DPW Work Order #

1. (This section 1 must be completed by Requester): Clearance is requested to proceed with work at the Detroit Arsenal on the project listed below involving excavation or utility disturbance per attached sketch and drawings.

Project Title: Project Location:

Contract No: Delivery Order No.:

Type of Facility/ work Involved : Check where applicable (cut /paste )

Pavements Drainage Systems Railroad Tracks Fire and Intrusion Alarm

Protection System Utility: Overhead Underground

Comm. Security Vehicular Traffic Flow Impact Other (specify)

Requester’s Name: E-mail:

Requester’s Job Title: Clearance Request Date:

Requester ‘s Company : Clearance termination Date Requester’s Signature Office Phone: Cell (Mobile) phone

2. Clearance Reviews

PO

C # Services/ Phone Extension POC

REMARKS See page 2 for protection Requirements Reviewer Signature Date

A. 1. Electrical Protect electrical lines

E N

G N

I E

E R

I N

G

2. Roads & parking Lots Protect roads, pavement

3. Water Distribution N/A

4. Sanitary Lines N/A

5. Industrial Waste lines N/A

6. Natural Gas Pipelines N/A

7. Oil & petroleum Pipelines N/A

8. Steam Distribution N/A

9. Compressed Air lines N/A

10. Comm. Lines /LAN/Phone Protect communication lines.

11. Storm drainage Protect storm drains, catch basins

12. Fire Alarm system N/A

13. Fire Lines Protect hydrants, PIV

14. Irrigation Sprinkler system Protect irrigation lines

15. Cathodic Protection N/A

16. Other (specify) Protect trees, bushes & lawn.

2.B. Eng Div C, Review 586.282.9369 2.C. Master Planning 586.282.0741 2.D. Environmental Div 586.282.5824 2.E. Fire Department 586.282.6021 2.F. Safety Office 586.282.6121 2.G. Comm /LAN/Phones 586.282.7988 2.H. Security /Traffic: 586.282.5511 2.I. Base Ops Contractor 586.282.5326

2.J. Community Utility Telephone, Gas, Electric, Other

Call MISS DIG at 1-800-MISS-DIG (800-842-7171 or 811)

TICKET NO:

2.K Other (specify)

3. Name of DPW Utility Reviewing Engineer: Isaac Freel Date Signed:

4. Requested Clearance APPROVED DISAPPROVED--

5. Approving Official: Isaac Freel Signature Date Signed:

6. Date of Site Pre-Excavation Walk thru: Pre-Excavation Walk thru Certification:

7. Certification of NPDES Permit and Macomb County SESC Permits obtained: N/A

SEE ATTACHED INSTRUCTIONS

FORM PWF-103 REV 09Oct 2014 page 2 of 4

INSTRUCTIONS

The Facilities Work Clearance Request is used for any wok (contract or in-house) work that may disrupt Vehicular traffic flow, installation utility services, protection provided by fire and intrusion alarm systems or routine activities of the installation. This form is used to coordinate the required work with key installation activities and organizations and keep customer inconvenience to a minimum. It is also used to identify potentially hazardous work conditions in an attempt to prevent accidents. The work clearance request is processed just prior to start of the work. If delays are encountered and conditions at the job site change (or may have changed) this work clearance must be reprocessed.

21. REMARKS: (This section describes specific precautionary measures to be taken before and during work accomplishment.

Specific comments concerning the approved method of excavations, hand or powered equipment should be included).

Protect following Utilities, Facilities & Services:

Protect following utilities & facilities: See also attached listing of Detroit Arsenal As-Built Utility Drawings and other drawings showing crossing or adjacent utilities that must be protected. The contractor shall field verify the location of all affected and adjacent underground utilities.

Protect following Utilities, Facilities & Services:

NOTES:

(1) Remark numbers such as 2.A.1 refer to the respective utility/reviewing office numbers on the previous page.

(2) Drawing of utilities basic maps were provided to Contractor.

A.1-15. Several utilities are in the proximity of the excavation, see drawings. Protect all utilities.

A.2. ROADS AND PARKING: (1) Contractor needs to coordinate with the DES and DPW to have parking spaces blocked with cones on evening before work. (2) The contractor is to maintain traffic along all roads and parking at all times, unless otherwise coordinated.

A.6. NATURAL GAS: (1) Contractor needs to coordinate work with Consumers Energy plans for gas main installation during same timeline. (2) Miss Dig Ticket Number and three days notices for staking utilities is required prior to digging.

A.16. OTHER:

1. Contractor shall provide two weeks notice advanced notification of shutdown of building entrances or any other closure. The Arsenal needs to notify the Arsenal Associates of any closure in advance.

2. No digging is allowed prior to all utilities being staked by Miss Dig, Base Operations and NEC (communication lines). Dig Permit is not valid until all utilities are marked in the field.

3. All digging more than 4 feet shall comply with trenching and shoring requirements as stated by OSHA.

SEE ATTACHED ADDITIONAL REQUIREMENTS, CONDITIONS AND NOTES

FORM PWF-103 REV 09Oct 2014 page 3 of 4

ADDITIONAL REQUIREMENTS, CONDITIONS AND NOTES

1. Restore all surfaces to original condition. All excavations shall be backfilled and compacted to assure no settlement.

2. The Contractor shall comply with Public Act 53 effective April 1 1975 as amended on December 21, 1989 by House Bill No.

5085. The Contractor shall notify the MISS DIG and the utility owners 14 calendar days before any excavation, tunneling, drilling, boring or demolition the work begins. The contractor shall notify and call MISS DIG at 1-800- 482-7171(or 811) and coordinate their work accordingly. In addition, the contractor shall hire proficient subcontractors to locate and field verify all Detroit Arsenal owned utilities shown on the drawings and within excavation / boring/ tunneling area (ground penetrating radar is recommended). The contractor shall coordinate with the COR for Base Operations contractor (BASOPS) and NEC (Network Enterprise Center) to provide a courtesy utility identification, however, the contractor is reminded that BASOPS and NEC are responsible for field locating and protecting the utilities and infrastructures and that this service by the Base Operations contractor is just a courtesy utility identification.

3. Request for all excavation permits must be accompanied by large-scale drawings of at least 1”=30’ in scale showing the existing utilities and infrastructures and how the new utilities and infrastructures are clearing them. NOTE: All requests without these drawings will be denied until those drawings are made available to DPW. The contractor can obtain a copy of the existing 1”=30’ drawings and other utilities and infrastructure maps from the Engineering Division, DPW. Request for excavation permits for geotechnical soil borings must be accompanied by drawings showing the location of the boring in a grid pattern to allow locating them from known surface features such as buildings, roads, etc. For details of the preparation of the acceptable design drawings, refer the Dig Permit Process

4. Contractor shall take precautions not to damage any existing structures, utilities, facilities and buildings. All repairs to damaged Detroit Arsenal utilities, infrastructures and facilities shall meet the Unified Facilities Guide Specification standards. & the Unified Facilities Criteria. Comply with the Detroit Arsenal fire, safety & Environmental requirements.

5. The contractor shall acquaint their employees & subcontractors with the work under this permit, and with the Government policies and procedures that are to be observed during the prosecution of the work and to develop a mutual understanding relative to the administration of the contract.

6. Contractor shall comply with the requirements of the following safety manuals: (a) US Army Corps of Engineers Engineering Manual EM 385-1-1, Safety and Health Requirements Manual (b) Code of Federal Regulation, part 1926, Safety Rules and Regulations for Construction, Occupational Safety and Health Administration Standards.

7. Traffic & parking Interruption: The contractor shall obtain phasing & approval requirements from Emergency Services Directorate & the using agency by submitting a Construction Impact Notification Form to the DPW. The Notification shall be a minimum 14 calendar days prior to planned work to allow processing.

8. AS-BUILTS: At the completion of the construction, the contractor shall provide a set of as-built blue prints. In addition, the contractor shall provide a set of as-built CADD drawings to the CADD department drawn in Micro-Station V8. The CADD file shall be archived on CD-ROM disc(s).

9. Utility Comments: The Detroit Arsenal utility comments are related to the route shown on the submitted drawings only. Any deviations from the proposed submitted Route shall require additional utility searches and approvals.

10. SECURITY STATEMENT WARNING:

10.A. Security Requirement: CONDITIONS FOR RELEASE of Plans to Contractors;

10.A.1. Released U.S. Government (USG) information is to be used for the purpose of this contract only, and will not be released to third parties without approval from US Army Garrison – Detroit Arsenal. Upon project completion, this information is to be destroyed or surrendered to the USG POC listed in Item 6 below.

10.A.2. No reproduction of released USG information is authorized for other than the contract's legitimate purpose.

10.A.3. Access to this information is to be controlled as UNCLASSIFIED / FOR OFFICIAL USE ONLY; and shall not be available for distribution under the Freedom Of Information Act (FOIA).

10.A.4. Information that is provided to the Contractor from the USG will be returned to the USG when no longer needed, or at the end of the contract. Under special provisions the USG may authorize the contractor to destroy the information by shredding (paper) or degaussing (magnetic media) to make unreadable and unrecoverable. Confirmation of destruction will be provided to the USG.

http://www.wbdg.org/ccb/browse_org.php?o=70 http://www.wbdg.org/ccb/browse_cat.php?o=29&c=4

FORM PWF-103 REV 09Oct 2014 page 4 of 4

10.A.5. All information and drawing provided shall not be posted on any internet web site.

10.A.6. The responsible USG POC for coordination of release and return of USG engineering drawings / information at the Detroit Arsenal, MI, is Matthew McKimmy(586) 282-0132 or Moiz Uddin (586) 282-6004.

10.B.1. Distribution authorized to US government agencies and contractors associated with TACOM Life Cycle Management Command (LCMC) or the United States Army Garrison - Detroit Arsenal in accordance with Army Regulation AR 530-1. For Official Use Only (FOUO) caveat is assigned so as not to place US personnel at risk, or compromise security procedures, or DOD information (Critical Infrastructure or Technology).

10.B.2. This document is not releasable to the public or media. This document must be returned to the US Government Contracting Officer or must be destroyed by shredding or tearing to make unreadable, when no longer needed. This document will not be sent over the INTERNET unencrypted, or posted to any public web sites. Other requests for this document shall be referred to Public Works, USAG-DTA, ATTN: IMMI -PW, 6501 East 11 Mile Road, Warren, MI 48397-5000, Commercial Phone 586- 282-6308.

11. (A) Contractors shall maintain vehicular traffic on roads at all times. Contractors may use directional bore where applicable, or block one lane only at a time and provide thick steel plates to main traffic. Contract shall maintain pedestrian traffic at all times.

(B) Contractor shall Restore all landscaping to original condition. (D) Contractor shall Provide Tracer cable in all new conduits and the means to identify the underground utility thru the tracer cable/ wire.(E) For GIS As-Builts, coordinate with DPW Mechanical Engineer, Engineering Division, Moiz Uddin (586) 282-6004.

12. LISTING OF ATTACHED DETROIT ARSENAL AS-BUILT DRAWINGS & OTHER DRAWINGS

SHEET NAME DRAWING Number SHEET # OF # REVISION DATE

Composite Utility Plan C-UP101-SITECOMP 1 of 1 5/14/2019

Asbestos Inspection Report B229 Spring 2019