J-15 2021 Excavation Permit Application Form fillable.pdf

2021 Excavation Application Form

PENTAGON RESERVATION

EXCAVATION PERMIT APPLICATION

WASHINGTON HEADQUARTERS SERVICES – FACILITIES SERVICES

DIRECTORATE

SUBMIT TO WHS.PENTAGON.FSD.MBX.ECM-CMD-EXCAVATION-PERMIT@MAIL.MIL

A. PROJECT INFORMATION TO BE COMPLETED BY CONTRACTOR OR GOVERNMENT PROJECT MANAGER (GPM)

AGENCY/GPM PHONE:

CONTRACTOR / POC: POC PHONE:

REQUESTED START DATE: _______________ PLANNED END DATE: __________________ DURATION (CAL.DAYS): ________

LIMIT OF DISTURBANCE: _________________ (Specify Square-fee or Acre) ATTACH A SCALED PDF DRAWING OF THE EXCAVATION SITE – ALL DOCUMENTS MUST BE DIGITAL – NO PAPER. WHEN REQUESTING A PERMIT FOR BORINGS, THE EXACT LOCATION MUST BE SHOWN

DESCRIPTION OF THE WORK TO BE PERFORMED: ☐ BORINGS/TEST PITS ☐ CONSTRUCTION (Check One)

B. PERMIT INSTRUCTIONS, CONTRACTOR CERTIFICATION, WHS APPROVAL, AND CLOSEOUT

1. This permit shall be used for any work on the Pentagon reservation that may disrupt underground communication or utility lines, including easements, or any below or above ground right of ways - including work that will penetrate more than 6" below ground level. Contractor questions regarding this permit should be directed to the Government POC.

2. Applicant MUST also submit an application to the Pentagon Building Management Office (PBMO) for a Space Use Permit DD Form 2798 (phone: 703-697-7351). Contractor MUST have BOTH the approved Excavation Permit and the PBMO Space Use Permit prior to commencing any on-site work. Permits shall then be posted on-site for the duration of the work.

3. The review and approval process is typically 20 business days. For any comments that are not addressed by the applicant within 5 business days the permit application will be subject to an extended review and potential cancellation. It will be the responsibility of the applicant to submit a new permit package. Review and issuance of this permit takes place PRIOR to applying for a Space Use Permit.

4. PRIOR TO SUBMITTAL THE CONTRACTOR MUST:

a. Contact the enterprise Facility Information Center (eFIC) office, convey scope of the dig and obtain existing conditions drawings. For geotechnical borings, provide locations. 703-614-1200

b. https://forms.office.com/pages/responsepage.aspx?id=BHxJVV- Tb0WGw4A3rOzszb9ntS7V77hFnj8dhTzGMlxUNE1DU0ZDU0hJWTNEOUtZQ09RQlJYSDVNUSQlQCN0PWcu

c. Contact Miss Utility (1(800)257-7777) and convey the scope of the dig and obtain a clearance number and clearance date. Enter Clearance Number and date in Section C. (Contacting Miss Utility is for their awareness only.

See instruction #3).

d. Contractor is solely responsible for tracing and marking all underground utilities within the area to be excavated. (Miss Utility does not have jurisdiction on Pentagon Reservation to mark utilities - but must be made aware of the excavation).

5. Contractor MUST use a utility locator to mark, then hand dig or use vacuum excavation within five feet of any written or known locations of an underground utility or communication line and within ten feet of all building boundaries. The use of Ground Penetrating Radar equipment requires an additional permit and an extended review period. Please contact PBMO for application and requirements.

6. Reporting Damage to Government Property: Contractor shall immediately notify the Building Operation Command Center (703-614-1597), the Heating & Refrigeration Plant (703-697-4478) and during business hours the Government POC for ANY damage to utility or communication lines.

7. Reporting unmarked utilities: If during excavation any unmarked utilities are encountered contractor shall immediately contact BOCC at 703-614-1597 and during business hours, the Government POC.

8. Consistent with contract terms, contractors are responsible for damages caused by activities associated with this permit, and compliance with contract terms and requirements for immediate repairs. Repairs must meet all current regulatory and code requirements and must be approved by the Government. The Government may exercise any remedy available under a contract, Pentagon policies and procedures, or the law if damages are not promptly remedied to the Government’s satisfaction.

9. APPROVAL: WHS EXCAVATION OFFICE WILL ONLY APPROVE THE PERMIT WHEN ALL UTILITY MARKINGS ARE FIELD VERIFIED AND CONCURRED BY THE UTILITY OWNERS AS WELL AS THE WHS EXCAVATION OFFICE. THE REQUESTOR/GOVERNMENT PROJECT MANAGER (GPM) IS RESPONSIBLE FOR COORDINATING WITH ALL

STAKEHOLDERS FOR FIELD VERIFICATION.

10. CLOSE OUT: Applicant MUST provide all closeout information (redlines, as-built drawings, spatial information, photographs, CAD files and verification documents) to the PBMO & eFIC office, when close out leads to site mailto:whs.pentagon.fsd.mbx.ecm-cmd-excavation-permit@mail.mil https://forms.office.com/pages/responsepage.aspx?id=BHxJVV-Tb0WGw4A3rOzszb9ntS7V77hFnj8dhTzGMlxUNE1DU0ZDU0hJWTNEOUtZQ09RQlJYSDVNUSQlQCN0PWcu https://forms.office.com/pages/responsepage.aspx?id=BHxJVV-Tb0WGw4A3rOzszb9ntS7V77hFnj8dhTzGMlxUNE1DU0ZDU0hJWTNEOUtZQ09RQlJYSDVNUSQlQCN0PWcu

2021 Excavation Application Form excavation. Redlines should show location of new or relocated utilities and other information which should be confirmed by the eFIC office. Permits will show an “open” status, and prohibit final project close out, until Government POC has confirmed receipt of the requested items

C. CONTRACTOR/COR ROUTING to MISS UTILITY/EFIC

1. MISS UTILITY 1(800) 257-7777 Clearance No: Clearance Date:

2. Third Party Utility Marking Company:_______________________________ Utility Marking Date:_________________

Signature (Government Representative) ______________________________

3. Will this project involve moving or removing any utilities? Yes _____ No ______

D. UTILITY OWNER - COORDINATION AND REVIEW ROUTING:

Organization POC Phone Field Verification of Markings Date

Signature

Pentagon Building Management Office

Jonathan Van Hoose

703-697-7351

Heating & Refrigeration Plant Mark Abels 703-697-4478

JSP - Telecom Infrastructure Evelyn King 703-697-0700

Washington Aqueduct Division Hanif Drzal 202-587-9366

Arlington National Cemetery (As required)

Joseph Bunton 703-614-0318

Dominion Energy

E. INFORMATION ONLY ROUTING:

Organization POC Phone Review Date Signature

SCD-Occupational Health Branch

Michael Gargano 703-693-3683

Pentagon Force Protection Agency

Leo Pereira 703-695-0851

WMATA JDACInquiries@wmata.com

VDOT anhallmark@transurban.com

F. ATTACHMENTS

☐ Excavation area exhibit ☐ MISS UTILITY documents ☐ Arlington county Land Disturbance Approval ☐ NPDES Permit (≥1ac)

☐Other____________________

I HAVE READ AND FULLY UNDERSTAND THE ABOVE

INSTRUCTIONS AND WILL CONTACT THE APPLICABLE

AGENCIES LISTED IN PART C BELOW FOR SITE CLEARANCE

PRIOR TO COMMENCING WORK.

THIS PERMIT HAS BEEN REVIEWED AND COORDINATED WITH

THE COMPONENTS LISTED IN PART D BELOW. THIS PERMIT

EXPIRES ON THE DATE SHOWN BELOW AND MUST BE

RENEWED IF WORK IS NOT COMPLETE.

Contractor Printed Name Date

Contractor Signature Date

WHS-FSD APPROVAL (SIGNATURE)

EXCAVATION PERMIT NO:

ISSUE DATE:

EXPIRATION DATE:

Government Printed Name Date

Government Signature Date

Excavation Permit Approval Requirements All requirements must be met before an approved Excavation permit is issued.

A Space Use Permit will not be approved until the approved Excavation permit is provided.

Initiate Application

• Step 1: Request Excavation support from eFIC - Official Party Responsible (OPR):

Government Project Manager(GPM)

Complete application

• Step 2: Provide complete application and supporting documents for review. (OPR:

GPM/Contractor)

• Step 3: Mark the Utilities in the area of work. (OPR:

GPM/Contractor)

• Step 4: Notify all utility owners for verifications of field markings. (OPR:

GPM/Contractor)

• Step 5: Obtain Utility Owner signatures based on field marking verification. (OPR:

WHS Excavation Office)

• Step 6: Conduct field verification of markings and provide subsequent approval ONLY if all above conditions met. (OPR: Overall Coordination – GPM;

Approval - WHS Excavation Office)

Execute Excavation

•Application approval: follow all recommendations provided with conditional approval.

• If during excavation any unmarked utilities are encountered, contact the BOCC immediately. 703-614-

• Immediately notify the Heating and Refrigeration Plant. 703-697-4478

Closeout Permit

• Step 7: Provide utility as-builts, redlines and other information (including accurate location coordinates and soil data reports for boreholes) to the eFIC office, WHS Excavation Office and PBMO office.(OPR:

GPM/Contractor)

•Please refer to the Electronic Data Standards (EDS) for acceptable documents & file formats.