Attachment_16_-_AF_Form_103v5_Work_Clearance_Request_with_header.pdf
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- Attached to
- CANNON AFB, NM SABER Federal contract opportunity
- Solicitation number
- FA4855-13-R-0009
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Attachment 16
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AF FORM 103v5, ------ Modified for Cannon AFB NM Page 1 of 4 PREVIOUS EDITIONS ARE OBSOLETE
BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST DATE PREPARED
(ddmmyy)
(See Instructions on Reverse)
1. Clearance is requested to proceed with work at: _________________________ __________________________________________
On Work Order No ____ _________________ Contract No.____________________________________involving excavation or utility disturbance per attached sketch. This area: has has not been staked or clearly marked.
2. TYPE OF FACILITY/ WORK INVOLVED
A. PAVEMENT D. FIRE DETECTION & PROTECTION SYSTEM
G. AIRCRAFT OR VEHICULAR
TRAFFIC FLOW
B. DRAINAGE SYSTEM E. UTILITY OVERHEAD UNDERGROUND H. SECURITY
C. RAILROAD TRACKS F. COMM OVERHEAD UNDERGROUND I. OTHER
3. DATE CLEARANCE REQUIRED
4. DATE OF CLEARANCE
5. SIGNATURE OF REQUESTING OFFICIAL 6. TELEPHONE NO. 7. ORGANIZATION
ORGANIZATION REMARKS (Use Reverse for additional comments} REVIEWER'S NAME & INITIALS
8. BASE OPERATIONS Bldg 135 Contact 48 hrs prior to clearance requirement 575-784-2801 - Call for clearance
9. MAINTENANCE OPERATIONS CENTER Bldg 164
Contact 48 hrs prior to clearance requirement 575-784-2135
10. SAFETY Bldg 1 Contact 48 hrs prior to clearance requirement 575-784-2811
11. COMMUNICATIONS Bldg 10 Contact 48 hrs prior to clearance requirement 575-784-6622 - Call for clearance and utility location
12. SCX Bldg 10
575-784-6103 - Call for clearance and utility location
13. SECURITY FORCES Bldg 575
575-784-4111
14. COMMERCIAL UTILITY COMPANIES
New Mexico 811
1- 800 -321-2537 - Note date & request number.
Date ____________________
Request # ________________
X TELEPHONE
X CABLE
. B
A
SE
C
IV
IL
E
N G
IN
EE
R
IN
G , B ld g
A. ELECTRICAL DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-4371 - Call for clearance and utility location
B. GAS DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-693-2565 - Call for clearance and utility location
C. WATER DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-693-2565 - Call for clearance and utility location
D. SEWER DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-693-2565 - Call for clearance and utility location
E. IRRIGATION SYSTEMS
HAND DIG ONLY (Unless waived by CEO) CEO Approved ________________________
F. POL DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-6742 - Call for clearance and utility location
G. ENVIRONMENTAL Contact 48 hrs prior to clearance requirement 575-784-1092
H. PAVEMENTS / GROUNDS Contact 48 hrs prior to clearance requirement 575-784-4383 - Call for clearance and utility location
I. FIRE PROTECTION Contact 48 hrs prior to clearance requirement 575-784-2578 - Call for clearance and utility location
J. EMCS / HVAC Contact 48 hrs prior to clearance requirement 575-784-1195 - Call for clearance and utility location
K. GEOBASE OFFICE Contact 48 hrs prior to clearance requirement 575-784-1610 - Call to update maps or utility tabs
16. OTHER (Specify)
17. REQUESTED CLEARANCE
APPROVED DISAPPROVED
18. TYPED NAME AND SIGNATURE OF APPROVING OFFICER (Chief of Operations Flight} 18a. DATE SIGNED (ddmmyy)
Milton.Mahon Typewritten Text Attachment 16
Milton.Mahon Typewritten Text
FA4855-13-R-0009
AF FORM 103v5, ------ Modified for Cannon AFB NM Page 2 of 4 PREVIOUS EDITIONS ARE OBSOLETE
19. Remarks. (This section describes specific precautionary measures to be taken before and during work accomplishment. Specific comments concerning the approved method of excavation, hand or powered equipment should be listed)
Equipment being used: ______________________________________________________________________________
1. Contractor will not proceed with any work until clearance has been coordinated as indicated by remarks that have been provided.
2. Any drawings provided indicate the APPROXIMATE location of the work area.
3. Contractor shall contact and give notice to all listed organizations by calling the phone numbers as listed in the remarks section next to each organization.
a. It is very important all clearance requests are made and understood by the contractor. The contractor shall log all calls and activities made to each organization as listed on the AF 103. The log information will be placed on page 3 of the AF 103. Each entry will be kept in a numbered, sequential order by date and organization. Note: If additional pages are required for the clearance log, record is to be attached to the original AF103.
b. If clearance is not required in the location of this request, the contractor will note the reviewer’s name and date/time the organization was contacted and indicate “No Action Required”.
c. If clearance is required by the organization, the contractor will coordinate a site meeting with the reviewer(s) representing that organization. The reviewer will physically spot the clearance issue and/or mark the location.
The contractor will then have the reviewer fill in his name and initials in the Reviewers Name and Initials column on page 1 for that organization. The contractor will also log on page 3 of the AF103, the meeting, date/time, person(s) name, and action taken.
4. As-builts for irrigation systems are not available. The contractor will ensure restoration of landscaping and repair of irrigation systems are completed, at no cost to the government, during the course of work.
5. The contractor will notify the Contracting Officer Representative (COR) or Project Manager (Box 5) if there are any questions or concerns to ensure proper coordination of this Work Clearance Request.
6. The contractor or his agent will maintain this clearance request on the site and make it available for review by any
Government representative upon request.
7. Notify Fire Department Control Center @ 575-784-2578 if any utilities are damaged after normal work hours.
Contractor Representative (Print Name) _______________________________ Telephone No. ____________
Signature_______________________________ Date_______________ (NOTE: Work cannot begin until signed by Contractor Representative)
Project Manager/COR (Print Name) __________________________________ Telephone No. ____________
Signature _______________________________ Date ______________
INSTRUCTIONS
The BCE work clearance request is used for any work (contract or in-house) that may disrupt aircraft or vehicular flow, base utility services, protection provided by fire and intrusion alarm system, or routine activities of the installation. This form is used to coordinate the required work with key base activities 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 the start of work. If delays are encountered and the conditions at the job site change (or may have changed) this work clearance request must be re-processed.
Action Log
AF FORM 103v5, ------ Modified for Cannon AFB NM Page 3 of 4 PREVIOUS EDITIONS ARE OBSOLETE
Base Utility Locater Action Taken Contractor Date/Time Electrical Distribution EMCS / Alarms / HVAC Gas Distribution
Water Distribution Sewer Distribution Irrigation / Landscaping Comm / Americom
GEO Base
New Mexico 811 Locater Action Taken Contractor Date/Time SuddenLink CenturyLink Plateau
Organization Name Action Taken Contractor Date/Time 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
370335
Chindit B lvd
Chindit B lvd
Air C ommando Way
Air C ommando Way
D.L. Ingram Ave
D.L. Ingram Ave
Unnam ed
Unnam ed
Alison Avenue
Alison Avenue Albright Avenue
Albright Avenue
En gin ee rs
W ay
En gin ee rs
W ay
Eureka Avenue
Eureka Avenue
Cochran Avenue
Cochran Avenue
Kermit Evans Avenue
Kermit Evans Avenue
Libera tor A ven ue
Libera tor A ven ue
Eagle C law
Blvd
Eagle C law
Blvd
Unnamed
Unnamed
103°19'24"W
103°19'24"W
°23 '39
"N
°23
'39 "N
1 inch = 443 feet 0 50 100 150 20025 Meters 0 210 420 630 840105
Feet
REV DATE INITIAL
SCALE: 1 IN = 2000 FT DATE: Aug 2012 PLAN
MAP: C-1AFI 32-7062, COMPREHENSIVE PLANNING
DRAWN BY: 27SOCES/CEPT
DESCRIPTION
DEPARTMENT OF THE AIR FORCE
AIR FORCE SPECIAL OPERATIONS COMMAND
BASE COMPREHENSIVE PLAN
INSTALLATION LAYOUT
FILE: S:\ CEPT\ 3_Base_Comprehensive_Plans\ C-Tabs Layout and Vicinit y Maps\ C-1 Inst allat ion Layout
CANNON AIR FORCE BASE, NEW MEXICO
CAD/GIS FORMAT: ESRI ArcMap 10
CANNON AIR FORCE BASE, NEW MEXICOCANNON AIR FORCE BASE, NEW MEXICO
DIG PERMIT BUILDING STOPSDIG PERMIT BUILDING STOPSThis map is for reference only . Although every effort has been made to ensure the accuracy of information, errors and conditions originating from physical sources used to develop the database may be reflec ted on this map. GeoBase shall not be liable for any errors , omiss ions, or damages that result from inappropriate use of this document.
This material is For Off ic ial Use Only (FOUO). Unauthorized reproduct ion, distribut ion, publication, or of this material is STRICTLY PROHIBITED. Des troy as "FOUO".
Prepared By:
Geospat ial Inform ation Off ice
27 Civil Engineering Off ice Cannon AFB, N M 88103×$
Date: 01/23/2013 Path: S:\CEPT\2_Work_Request\4_27MSG-MDG\SOCES\CEP Misc\Dig Permits\Dig Permit Building Stops.mxd
MAGNETIC DECLINATION:
AS OF DATE:
ANNUAL CHANGE:
AIRFIELD ELEVATION:
7° 54' 00"
SEP 2008
00° 07' W 4294.00ft
COORDINATE SYSTEM:
DATUM:
UNITS:
UTM Zone 13N
WGS 84
Meters
| AF103v5 1 |
| Dig Permit Building Stops |
File details come from the government source that posted it. Updated .