Excavation Permit Form.pdf
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- Solicitation number
- FA520920B0008
About this file
This document is an excavation permit form used by the Department of Public Works at a military installation. The form requires information on the location and type of excavation work, dates for when the permit is required and expires, and signatures from various review organizations including Environmental, Safety, Master Planning, Real Estate, Project Management, Roads and Grounds, Fire Department, Communications, and the Director of Public Works who approves or disapproves the permit. Reviewing organizations must concur or non-concur with comments and note whether drawings are attached. The contractor must identify all utilities in the excavation area, verify locations, monitor for changes indicating unmarked utilities, and show any additional located utilities on as-built drawings. Precautionary measures and the excavation method must be described in remarks.
The related federal contract opportunity is a solicitation to repair the roof of Building 200 at Yokohama North Dock in Japan for the Department of the Air Force Pacific Air Forces. Drawings will be provided at a site visit. The solicitation is for roof repair and removal of HVAC ducts in the building.
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Text version
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C. Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTSO
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DPW EXCAVATION PERMIT (Rev. 18 April 2017)
DATE PREPARED
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
1.
EXCAVATION PERMIT is requested to proceed with work at _______________________________ Project No. _________________________, Contract No. __________________________, involving excavation or utility disturbance per attached detailed sketch provided by the Contractor.
The Contractor shall detail the disturbed area limits and anticipated depth. The work area Has □ Has not □ been staked or clearly marked.
2. TYPE OF FACILITY / WORK INVOLVED
A. PAVEMENTS B. DRAINAGE
SYSTEMS
C. FIRE DETECTION D. UTILITY
OVERHEAD
UNDERGROUND
OVERHEAD
UNDERGROUND
E. COMM.
F. AIRCRAFT OR G. SECURITY H. OTHER - DRILLING FOR POLES OR POSTS, ECT... (Specify)
The DPW Excavation Permit is used for any excavation work (contract or in-house) that may disrupt vehicular traffic flow, installation utility services, communication services, cable T.V., fire and intrusion alarm system, or routine activities of the installation. This permit is used to coordinate the required work with key installation activities and keep community inconveniences to a minimum. It is used to identify potentially hazardous work conditions to prevent accidents.
The contractor shall perform a general site survey and locate all utilities within the effected area(s) prior to any excavation, drilling, or ground surface disturbance, 4 inches or more in depth, by using the utility drawings and by toning the area. The contractor shall verify that all water (hot & cold), steam, natural gas, propane, sewer, electrical, drainage utilities, and communication cables, etc., have been identified. The equipment operator shall closely monitor the excavated material for significant changes in the color, size (gradation), and type of material. Such changes may indicate the presence of unmarked utilities. If such changes are observed, the contractor shall cease all excavation immediately and probe by hand. Damages to utilities other than what is identified, will not relieve the contractor of any damages and will be repaired and restored immediately at his own expense. All utilities that are not shown on the plans, but have been located in the field shall be shown on the construction as-built drawings.
The contractor shall submit a completed permit to the Operations & Maintenance Division and Engineering Division, Contract Management Branch for their records. The contractor shall maintain his permit on site at all times during the excavation work. This document becomes a certified excavation permit after all agencies have concurred in the appropriate sections and the approving authority has signed this permit.
In accordance with FAR 52.2367, Permits and Responsibilities, the contractor shall, without additional expense to the Government, be responsible for obtaining any necessary licenses or permits and for complying with any local laws, codes, and regulations applicable to the performance of the work. The contractor shall also be responsible for all damages to persons or property that occur as a result of the contractor's fault or negligence.
3.
4. DATE EXCAVATION PERMIT REQUIRED 5. DATE EXCAVATION PERMIT TERMINATED
6. REQUESTING OFFICIAL (Name and Signature) 7. PHONE NO. 8. ORGANIZATION
EXCAVATION REVIEW
ORGANIZATION *ACTION* (Provide drawings, Concur/ Non-Concur with comments, attach additional pages if necessary)
REVIEWER'S NAME
D ire ct or at e of P ub lic
W or ks
9.
SIGNATURE
AND PROTECTION
SYSTEMS
VEHICULAR
TRAFFIC FLOW
CZ & SFHA (CZ Bldg. 646) SGD (Bldg. 161-1) YND & APC (YND Bldg. 347)
CZ & SFHA (CZ Bldg. 646) SGD (Bldg. 161-1) YND & APC (YND Bldg. 347)
CZ & SFHA (CZ Bldg. 646) SGD (Bldg. 161-1) YND & APC (YND Bldg. 347)
ELECTRICAL & A/C
BRANCH
MECHANICAL &
SANITATION BRANCH
BUILDING & STRUCTURE
BRANCH
O
M D
IV
D.
O
M D
IV
E.
F.
G.
H.
I.
CONCUR or NON-CONCUR w/COMMENTS
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
ENVIRONMENTAL
DIVISION CHIEF
(CZ Bldg. 642)
CONCUR or NON-CONCUR w/COMMENTS
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
SAFETY OFFICE
(CZ Bldg. 102)
CONCUR or NON-CONCUR w/COMMENTS
MASTER PLANNING DIVISION
CHIEF
(CZ Bldg. 642)
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
REAL ESTATE BRANCH
(CZ Bldg. 642)
PROJECT MANAGEMENT
BRANCH
(CZ Bldg. 642)
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
CONCUR or NON-CONCUR w/COMMENTS
O&M Will Mark Utilities On: ___________
D ire ct or at e of P ub lic
W or ks
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
Drawings Attached - YES or NO CONCUR or NON-CONCUR w/COMMENTS
CONCUR or NON-CONCUR w/COMMENTS
11. PROVOST MARSHAL OFFICE
12.
13. COMMUNICATIONS
14. COMMERCIAL UTILITY
COMPANY
(Tel, Gas, Elec…)
15. OTHER (Specify)
16. REMARKS (This section must describe 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 included. Attach details of excavation with this permit.)
If you have any questions, contact the Chief, Operations and Maintenance Division, DPW, at 263-3609.
REQUESTED CLEARANCE
DATE SIGNATURE OF APPROVING OFFICER (Director, DPW)
APPROVED DISAPPROVED
9.
ORGANIZATION REVIEWER'S NAME SIGNATURE
EXCAVATION REVIEW
CZ & SFHA (CZ Bldg. 645) SGD (Bldg. 161-1) YND & APC (YND Bldg. 347)
ROAD & GROUND
BRANCH
CZ & SFHA (CZ Bldg. 228) SGD (Bldg. 130-3) YND (Bldg. 331) APC (Bldg. 1)
78th Signal Battalion (CZ Bldg. 123)
CZ & SFHA (CZ Bldg. 645) SGD (Bldg. 161-1) YND & APC (YND Bldg. 347)
O&M Division Chief or Sub Fac Eng Chief
10. FIRE DEPARTMENT
CZ & SFHA (CZ Bldg. 238) SGD (Bldg. 143-5) YND & APC (YND Bldg. 437)
*ACTION* (Provide drawings, Concur/ Non-Concur with comments, attach additional pages if necessary)
Excavation Permit
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