S02 Solicitation Attachment E GLA Specific Requirements.pdf

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VAGLA ENERGIZED ELECTRICAL WORK PERMIT

Supervisor, Contractor’s Competent Person, or VA Project Engineer (if no contractor):

Printed Name: Sign:

Work start/stop dates: From: Time AM[ ] To: Time AM[ ]

_____ PM[ ] ______ PM[ ]

EQUIPMENT NAME, LOCATION AND DESCRIPTION: Work order number:

DESCRIPTION OF WORK TO BE PERFORMED:

JUSTIFICATION FOR ENERGIZED WORK (reason why job cannot be postponed until shutdown):

ELECTRICAL ENERGY SOURCES PRESENT:

Check all that apply:

[ ] 120 volts [ ] 277 volts [ ] DC [ ] 208 volts [ ] 480 volts [ ] Emergency power [ ] 240 volts [ ] Other (describe):____________ [ ] <50 volts (permit MAY not be required)

RESULTS OF SHOCK AND FLASH ANALYSES:

Flash Protection Boundary (2nd degree burn potential): _____inches Maximum Exposure: _____cal/ cm2

Limited Approach Boundary (shock protection boundary): _____inches Minimum PPE level: _____

(Note: Employee work on Levels 3 and above is PROHIBITED (work must be contracted) REQUIRED PERSONAL PROTECTIVE EQUIPMENT: Cal/Volt Rating [X] Non-melting, untreated natural fiber clothing, all layers [ ] Voltage-rated rubber gloves (Level 1+) ______ [X] Shirt (long-sleeve) [ ] Flame-retardant coveralls (Level 1+) ______ [X] Pants (long) [ ] Type 1, Class E hard hat (Levels 1&2) ______ [X] Polycarbonate safety glasses [ ] Arc-rated face shield (Levels 1&2) ______ [X] Ear protection [ ] FR flash suit and hood (Level 3+) ______ [X] EH-rated footwear [ ] Switchboard matting/insulated blankets ______ [X] Insulated tools [ ] Other items (specify)________________ ______ [X] Leather gloves (inspect before each use) BARRIERS (to prevent access to flash protection and limited approach boundaries) [ ] Locked access [ ] Electrical hazard signs [ ] Barrier tapes, stanchions [ ] Other (describe):____________________

SUPERVISOR’S PRE-JOB BRIEFING BY: Printed Name: Sign:

Workers are “qualified” (see 29 CFR 1910.399) with a journeyman electrical rating.

Safety watch is required. This person must be “qualified,” able to disconnect all power sources with proper PPE, and have immediate access to a telephone or radio to summon help in the event of an emergency.

All jewelry and metal apparel has been removed.

Confirmed that insulated tools, EH-rated footwear, switchboard matting, FR-clothing and other equipment is available, in good condition, and appropriate for the hazard level to be encountered.

Verified that barricades and warning signs are installed.

Outlined safe work practices to be followed (document under Special Instructions, below).

STOP WORK POINTS: Permit is void if any unexpected energy is found, or equipment has been modified since the permit was issued.

Special instructions and specific job-related hazards:

QUALIFIED PERSONS that understand and agree to the above plan:

Printed name(s): Signature(s) & Date: Printed name(s): Signature(s) & Date:

SAFETY WATCH:

Printed name: Signature & Date: Printed name: Signature & Date:

APPROVALS Print Sign Date

Peer review (2nd qualified person that agrees the work can be safely completed)

Project Engineer

Maintenance Supervisor

Facility Manager

Safety Officer

Medical Center Director

Work completed date/time: List any unexpected hazards or “STOP WORK” issues encountered:

EQUIPMENT NAME LOCATION AND DESCRIPTION Work order number:

DESCRIPTION OF WORK TO BE PERFORMED:

JUSTIFICATION FOR ENERGIZED WORK reason why job cannot be postponed until shutdown:

Other describe:

Flash Protection Boundary 2nd degree burn potential:

Maximum Exposure:

Limited Approach Boundary shock protection boundary:

Minimum PPE level:

Other items specify:

CalVolt Rating 1:

CalVolt Rating 2:

CalVolt Rating 3:

CalVolt Rating 4:

CalVolt Rating 5:

CalVolt Rating 6:

CalVolt Rating 7:

Other describe_2:

Workers are qualified see 29 CFR 1910399 with a journeyman electrical rating: Off

Safety watch is required This person must be qualified able to disconnect all power sources with proper: Off undefined_2: Off

Confirmed that insulated tools EHrated footwear switchboard matting FRclothing and other equipment is: Off undefined_3: Off

Outlined safe work practices to be followed document under Special Instructions below: Off

STOP WORK POINTS Permit is void if any unexpected energy is found or equipment has been modified since the: Off

Special instructions and specific jobrelated hazards:

Special instructions and specific jobrelated hazards_2: Off

QUALIFIED PERSONS that understand and agree to the above plan:

Printed namesRow1:

Signatures DateRow1:

Printed namesRow1_2:

Signatures DateRow1_2:

Printed namesRow2:

Signatures DateRow2:

Printed namesRow2_2:

Signatures DateRow2_2:

SAFETY WATCH:

Printed nameRow1:

Signature DateRow1:

Printed nameRow1_2:

Signature DateRow1_2:

Peer review 2nd qualified person that agrees the work can be safely completed:

Project Engineer:

Maintenance Supervisor:

Facility Manager:

Safety Officer:

Medical Center Director:

Work completed datetime List any unexpected hazards or STOP WORK issues encountered:

Text1:

Text3:

Time:

Check Box4: Off

Check Box5: Off

Check Box6: Off

Check Box7: Off

Text8:

Text9:

Check Box10: Off

Check Box11: Off

Check Box12: Off

Check Box13: Off

Check Box14: Off

Check Box15: Off

Check Box16: Off

Check Box17: Off

Check Box18: Off

Text19:

Text23:

Check Box28: Off

Check Box29: Off

Check Box30: Off

Check Box31: Off

Check Box1: Off

Check Box2: Off

Check Box3: Off

Check Box8: Off

Check Box9: Off

Check Box19: Off

Check Box20: Off

Lockout/ Tagout Safety Permit

Project # and Title: ________________________________________________________

Date:

Time Issued_______________

Expiration Time;____________

Permit Issued to:

Maintenance Outside Contractor Name: ____________________________________________

Checked precautions shall be observed

Tag & Disconnect Electric Equipment

Lines Blinded

Valves Closed & Tagged

Locked Out

Lines Disconnected

Bleeders Open

Fire Extinguishers at Site

Contains Sparks

Keep Area free of combustibles

Barricade Area

Shield Arc

Protective Equipment Required

Wear Goggles - Face Shield

Wear Gloves - Rubber Thermal

Wear Hood- Acid Thermal

Wear Suit- Rubber Thermal

Wear Rubber Boots

Wear Safety Belt & Line

Wear Respirator – Dust, Chemical

Other precautions:

PERMIT CONDITIONS AND REQUIREMENTS UNDERSTOOD APPROVALS

___________________________________SIGNED

ENGINEER/ FOREMAN / CRAFTSMAN (CIRCLE ONE)

Safety Inspector

Signed Time

Work must begin within ninety minutes of issuance of this permit.

If the work is interrupted the foreman craftsman, or contractor must indicate equipment condition to operations foreman or operator when leaving job for more than two hours or when job is complete.

JOB COMPLETE

JOB INCOMPLETE

THIS PERMIT IS TO BE KEPT ON THE JOB UNTIL WORK IS COMPLETED, PERMIT EXPIRES OR IS REVOKED

Project and Title:

Time Issued:

Expiration Time:

Outside Contractor Name:

Other precautions:

SIGNED:

Signed:

Time:

JOB COMPLETE:

Check Box52: Off

Check Box53: Off

Check Box54: Off

Check Box55: Off

Check Box56: Off

Check Box57: Off

Check Box58: Off

Check Box59: Off

Check Box60: Off

Check Box61: Off

Check Box62: Off

Check Box63: Off

Check Box64: Off

Check Box65: Off

Check Box66: Off

Check Box67: Off

Check Box68: Off

Check Box69: Off

Check Box70: Off

Check Box1: Off

Check Box2: Off

CRANE PERMIT APPLICATION

(Crane, Boom truck, and or Pump Truck)

Permit Number: ____________________________ Date Permit Issued: ________________

Date of Lift: _______________________________

Name of Primary Contractor: __________________________ Contractors Phone Number: ________________________

Project Number: _____________________________________

ACOE Project Engineer’s Name: _________________________ Phone Number: _________________________________

VA Projector Engineer’s Name: __________________________ Phone Number: _________________________________

Location of Operation: _______________________________________________________________________________

Crane Owner: ______________________________________________________________________________________

Crane’s Office Address: ______________________________________________________________________________

Office Phone Number: _______________________________________________________________________________

Make of Crane: _____________________________________________________________________________________

Year of Manufacture: ______________ Model Number: ________________ Serial Number: _______________________

Crane Capacity: ______________________ Date of Last Inspection: ___________________________________________

Type of Crane: ______________________________________________________________________________________

Does the Crane Operator hold the relevant certificate of competency: Yes ____ No ____

Is there a legible copy of the operator’s manual with the crane (English): Yes ____ No ____

Is a logbook kept with the crane: Yes ____ No ____

Is lifting gear of adequate capacity, in good order and appropriately marked: Yes ____ No ____

Are their spotters assigned to prevent unauthorized personnel from entering the work area: Yes ____ No ____

Crane Safety Plan and Load Charts Submitted: Yes _____ No ____

Is a Safety Meeting held prior to all operations: Yes: ____ No ____

Operator’s Name (Print): __________________________________ Signature: __________________________________

Date: _________________________

Project Engineer Name (Print): ____________________________ Signature: __________________________________

Safety Office Approval Name (Print): ________________________ Signature: _________________________________

Permit Number:

Date Permit Issued:

Date of Lift:

Name of Primary Contractor:

Contractors Phone Number:

Project Number:

COE Project Engineers Name:

Phone Number:

V Projector Engineers Name:

Phone Number_2:

Location of Operation:

Crane Owner:

Cranes Office ddress:

Office Phone Number:

Make of Crane:

Year of Manufacture:

Model Number:

Serial Number:

Crane Capacity:

Date of Last Inspection:

Type of Crane:

Yes:

No:

Yes_2:

No_2:

Yes_3:

No_3:

Yes_4:

No_4:

Yes_5:

No_5:

Yes_6:

No_6:

Yes_7:

No_7:

Operators Name Print:

Date:

Project Engineer Name Print:

Date_2:

Safety Office Approval Name Print:

Date_3:

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract.

EXCAVATION PERMIT (Section 1: Complete prior to digging/drilling) Facility No./Project No./Permit No./

1. Work Name. / Project title

2. Task/Project No.

3. Location of Excavation

4. Originated By

Date

5. Permit Renewal due date:

6. Drawings Required (identification No.)

7. Other Affected Drawings or Documents (if any)

8. Estimated start and stop time of work/Specific location and nature of the work:

9. Contractors “Competent Person” Print/Sign below. *

*CP must have received 30hr OSHA Construction training as well as formal training in Excavation safety.

10. Excavation Requirements Planning Checklist (check appropriate blocks to determine supplemental approvals) Yes No

Has review of site drawings been executed and proximity of utilities been determined? (Utility locations must have proper ground markings once they are identified)

Are soil samples required to determine soil contamination?

Has coordination with local authority been established?

If not, has sufficient efforts been made to determine utility locations?

Is soil or concrete removal to an offsite location necessary?

Has the proposed worksite and workplan been evaluated and deemed eligible per historic preservation standards and guidelines? (State Historic Preservation Office (SHPO), Native American Graves Protection and Repatriation Act (NAGPRA), Etc.)

11. List Facilities, Services, Structures, and Utilities Affected by Excavation

Approvals

12. Contractor Construction Supervision Date

14. Facility Engineering/Project Engineer

15. Facility Safety Date

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract.

DATE:

NAME OF

REVIEWER:

M

ET

N

O T

M

ET

N

/A

REQUIREMENT

1. Are the estimated locations of utility installations, such as sewer, telephone, fuel, electric, water lines, or any other underground installations that reasonably may be expected to be encountered during excavation work determined prior to opening an excavation? [OSHA 29 CFR 1926.651(b)(1)]

2. Are utility companies contacted within established or customary local response times, advised of the proposed work, and asked to establish the location of utility underground installations up to their own meters prior to the start of actual excavation? [OSHA 29 CFR 1926.651(b)(2)]

3. On VHA property, is the proposed dig site being marked, “as built” drawings reviewed, and visual indicators (manholes, valves, meters, permanent markers, etc…) of the utilities being utilized to establish the location of utility underground installations by in-house VHA personnel or a contracted private locator service? [OSHA 29 CFR 1926.651(b)(2)]

4. On VHA property, are locations of utility underground installations being marked and maintained by use of stakes, paint, flags, or other clearly identifiable materials to show the field location of underground facilities, in accordance with the current color code standard of the American Public Works Association.? [OSHA 29 CFR 1926.651(b)(2)]

5. If utility companies or the VHA cannot locate underground utility installations or cannot establish the exact location of these installations, are excavation contractors proceeding with caution and using detection equipment or other acceptable means to locate utility installations (careful hand digging, pot-holing and vacuum excavation, hand tools that use air or water under pressure, exploratory bar, or other)? [OSHA 29 CFR 1926.651(b)(2)]

6. When excavation operations approach the estimated location (within 2 feet) of underground installations, are the exact location of the installations determined by safe and acceptable means (careful hand digging, pot-holing and vacuum excavation, hand tools that use air or water under pressure, exploratory bar, or other)? [OSHA 29 CFR 1926.651(b)(3)]

7. While the excavation is open, are underground installations protected, supported or removed (Lockout/Tagout, supports built, etc…) as necessary to safeguard employees?

[OSHA 29 CFR 1926.651(b)(4)]

8. Are Activity Hazard Analyses and excavation permits being completed prior to opening excavations? (FAR 52.236-13, Accident Prevention; VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements, Subtopic 1.5 & 1.18)

9. Where workers enter an excavation greater than 5 feet in depth, are soils being classified in accordance with OSHA classification system (Solid Rock, Type A, Type B, or Type C)?

[OSHA Directive CPL 2-0.124; VHA Directive 2011-036, Subpar. 4(l)(7)] Note: If using an excavation protective system of sloping or benching, then the soil classification cannot be Solid Rock or Type A. Thus, the angle of repose cannot be steeper than 1 to 1 (45 degrees) (OSHA 29 CFR 1926.652 & associated Appendix A; VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements, Subtopic 1.18, Par. C)?

10. Where workers enter an excavation greater than 5 feet in depth, are protective systems being designed in accordance with 29 CFR 1926, Subpart P, Appendices B to E or designed by Professional Engineer [OSHA 29 CFR 1926.652(a)] Note: excavations in excess of 20 feet in depth must be designed by PE and sloping or benching systems cannot have an angle of repose steeper than 1 to 1 (45 degrees) as provided above.

Reviewer Signature:

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract.

EXCAVATION/TRENCH SAFETY CHECKLIST

DAILY INSPECTION

Inspection of the excavation/trench, including adjacent areas and protective systems, are conducted daily by a Competent Person. The Competent Person inspects for evidence of situations that could result in possible cave-ins, indications of protective system failures, indications of a hazardous atmosphere, and other hazardous conditions.

Inspections are conducted after every rainstorm and any other potential hazard-increasing occurrence.

Sloping and shoring comply with OSHA 1926.651 and 1926 Subpart P App B.

The following items (as applicable) are verified and the results documented in the Excavation and Trenching Permit:

The excavation permit is valid, signed, and dated. Excavation began within 60 days of facility/system owner’s signature or by the permit expiration date.

Scan document is valid.

Employees have received a daily briefing on the composite scan drawing, the excavation/trench’s special requirements, and excavation hazards.

The area surrounding the excavation/trench has been properly protected and barricaded.

Ensure “U DIG” or other applicable utility company has been notified 10 days before excavation and every 10 days during excavation (as/if applicable).

Utilities have been located, protected, and marked (refer to composite scan drawing).

The excavation (if 5 feet [1.5 meters] or deeper) is properly sloped or shored.

Foundations, structures, and appurtenances, for example, are supported or underpinned.

Protective systems being used comply with the manufacturer’s instructions or engineering designs.

Sloping or protective systems have been checked for evidence of failure (such as soil distress, structural member damage, or soil fissures).

A means of egress (such as a stairway, ladder, or ramp) is provided within 25 feet (7.6 meters) of each person in the excavation/trench.

Walkways or bridges with standard handrails are provided where personnel are required to cross the excavation/trench.

Excavated materials have been placed at least 2 feet (0.6 meter) away from the edge of the excavation/trench.

A determination has been made whether or not to classify the excavation/trench as a confined space.

Note: If the excavation/trench is classified as a confined space, ensure monitoring (as required on the confined space entry permit, if any) is performed before employees are allowed to enter.

The excavation/trench is safe for employees to enter.

Pre-task planning documents have been updated, as required, to reflect changes in work scope, site conditions, or hazard change.

Planning documents have been discussed with, and signed by, affected employees.

Corrective measures have been taken to eliminate existing or predictable hazards.

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract.

EXCAVATION AND TRENCHING

DAILY INSPECTION LOG

The applicable items listed on page 3 of the Excavation and Trenching Permit were verified. Deficiencies observed are noted with the corresponding action that was taken to eliminate the hazard.

Date Time Condition

Comments/Deficiencies Noted Corrective Action Taken Inspected By

(Competent Person) Accept Not Accept

EXCAVATION/TRENCH SAFETY CHECKLISTDAILY INSPECTION

EXCAVATION AND TRENCHING

Date

Excavation/Trench Inspection and Entry Authorization Form

*This form will be completed by the Competent Person daily (at a minimum) or when site conditions change. The completion of this form is mandatory prior to work in any excavations or trenches 4’ in depth or greater. A corresponding Excavation/Trenching P lan must be accepted by the VA prior to work in any excavations/trenches 5’ in depth or greater.*

PRIME CONTRACTOR: SUBCONTRACTOR:

COMPETENT PERSON: LOCATION:

DATE: TIME: NUMBER OF CREW MEMBERS:

Dimensions Depth = Min. Max. Soil Type Manual Test Measurement Top = Width Length Solid Rock Type B Penetrometer Bottom = Width Length Type A Type C Thumb Penetration

HAZARDOUS CONDITIONS* (Visual Checks) Yes No PERIMETER CONSIDERATIONS Yes No n/a Saturated soil/standing or seeping water? Spoils located at least 2’ away from edge?

Bulging walls? Materials located at least 2’ away from edge?

Rapid drying / shrinkage? Class 1, 2, or 3 perimeter protection in place?

Vibration from equipment / traffic? Backhoe located at end of trench?

Cracked or fissured walls? Spotter working with the backhoe?

Undercutting? Exposed to the general public?

Floor heaving? MPM requirements completed?

Super imposed loads? LADDER/EGRESS LOCATION Yes No n/a

Exposed utilities? Located within protected area?

Atmospheric testing required? Located within 25 feet of safe travel?

Structures adjacent to trench? Extends 36” above landing and secured in place?

Trees or roots in the work area? Maximum ramp angle without cleats 25°?

*If the hazards listed above result in a fall hazard or confined space, a corresponding Site Specific Fall Protection and Prevention Plan

(SSFPPP) or Confined Space Plan (CSP) must be developed and accepted before work can commence.

SHORING Yes No COLOR CODE FOR UTILITY MARKING based on ANSI Z-53.1

Manufacturer tabulated data sheets on site? PROPOSED EXCAVATION WHITE

Shoring inspected for defects/damage? ELECTRIC POWER LINES, CONDUITS, LIGHTING CABLES RED

Trench shield in use? POTABLE WATER BLUE

Speed shores in use? GAS, STEAM, CONDENSATE, OIL COMPRESSED AIR YELLOW

Speed shores pumped to design pressure? TELECOMMUNICATIONS, ALARM OR SIGNAL LINE ORANGE

Plywood or sheeting to be used? TEMPORARY SURVERY MARKINGS PINK

SLOPING SEWER AND STORM DRAINS GREEN

Type A soils at a minimum of 3/4:1 (53°)? RECLAIMED WATER, IRRIGATION, CHILLED LINES PURPLE

Type B soils at a minimum of 1:1 (45

)? OTHER LIGHT BLUE

Type C soils at a minimum of 1 1/2:1 (34°)? EXCAVATION/TRENCH COMPETENT PERSON SIGNATURE

X

BENCHING

Type A and B soils benched? (NO Type C) Max height of Type B soil bench 4’?

Names of personnel authorized to enter the excavation/trench:

PRIME CONTRACTOR:

SUBCONTRACTOR:

COMPETENT PERSON:

LOCATION:

DATE TIME:

NUMBER OF CREW MEMBERS:

Dimensions:

Penetrometer:

Thumb Penetration:

PERIMETER CONSIDERATIONS:

YesSaturated soilstanding or seeping water:

NoSaturated soilstanding or seeping water:

YesSpoils located at least 2 away from edge:

NoSpoils located at least 2 away from edge:

naSpoils located at least 2 away from edge:

YesBulging walls:

NoBulging walls:

YesMaterials located at least 2 away from edge:

NoMaterials located at least 2 away from edge:

naMaterials located at least 2 away from edge:

YesRapid drying shrinkage:

NoRapid drying shrinkage:

YesClass 1 2 or 3 perimeter protection in place:

NoClass 1 2 or 3 perimeter protection in place:

naClass 1 2 or 3 perimeter protection in place:

YesVibration from equipment traffic:

NoVibration from equipment traffic:

YesBackhoe located at end of trench:

NoBackhoe located at end of trench:

naBackhoe located at end of trench:

YesCracked or fissured walls:

NoCracked or fissured walls:

YesSpotter working with the backhoe:

NoSpotter working with the backhoe:

naSpotter working with the backhoe:

YesUndercutting:

NoUndercutting:

YesExposed to the general public:

NoExposed to the general public:

naExposed to the general public:

YesFloor heaving:

NoFloor heaving:

YesMPM requirements completed:

NoMPM requirements completed:

naMPM requirements completed:

YesSuper imposed loads:

NoSuper imposed loads:

LADDEREGRESS LOCATION:

YesExposed utilities:

NoExposed utilities:

YesLocated within protected area:

NoLocated within protected area:

naLocated within protected area:

YesAtmospheric testing required:

NoAtmospheric testing required:

YesLocated within 25 feet of safe travel:

NoLocated within 25 feet of safe travel:

naLocated within 25 feet of safe travel:

YesStructures adjacent to trench:

NoStructures adjacent to trench:

YesExtends 36 above landing and secured in place:

NoExtends 36 above landing and secured in place:

naExtends 36 above landing and secured in place:

YesTrees or roots in the work area:

NoTrees or roots in the work area:

YesMaximum ramp angle without cleats 25:

NoMaximum ramp angle without cleats 25:

naMaximum ramp angle without cleats 25:

Depth Min Max SoilType Manual Test MeasurementRow3:

SHORING:

YesManufacturer tabulated data sheets on site:

NoManufacturer tabulated data sheets on site:

PROPOSED EXCAVATION:

WHITE:

YesShoring inspected for defectsdamage:

NoShoring inspected for defectsdamage:

RED:

YesTrench shield in use:

NoTrench shield in use:

POTABLE WATER:

BLUE:

YesSpeed shores in use:

NoSpeed shores in use:

YELLOW:

YesSpeed shores pumped to design pressure:

NoSpeed shores pumped to design pressure:

YesPlywood or sheeting to be used:

NoPlywood or sheeting to be used:

TEMPORARY SURVERY MARKINGS:

PINK:

YesSLOPING:

NoSLOPING:

SEWER AND STORM DRAINS:

GREEN:

YesType A soils at a minimum of 341 53:

NoType A soils at a minimum of 341 53:

PURPLE:

YesType B soils at a minimum of 11 45:

NoType B soils at a minimum of 11 45:

OTHER:

YesType C soils at a minimum of 1 121 34:

NoType C soils at a minimum of 1 121 34:

YesBENCHING:

NoBENCHING:

YesType A and B soils benched NO Type C:

NoType A and B soils benched NO Type C:

YesMax height of Type B soil bench 4:

NoMax height of Type B soil bench 4:

Names of personnel authorized to enter the excavationtrench:

min:

max:

width:

length:

bott width:

bott length:

rock: Off

A: Off

C: Off

B: Off

APPLICANT’S INFORMATION to Request a VA-ID (Verified by prime contractor and prior start of any work)

PART I - APPLICANT INFORMATION (Applicants must present 2 matching valid USA and/or State IDs each time)

FIRST NAME (as it appears on valid IDs)

MIDDLE NAME

LAST NAME

SOCIAL SECURITY NO.

HOME PHONE NUMBER (or CELL)

HOME E-MAIL ADDRESS (Optional)

HOME STREET ADDRESS (USA – No PO Box)

HOME STATE

HOME CITY

ZIP CODE

DATE OF BIRTH

RACE

COLOR OF: EYES / COLOR OF: HAIR

HEIGHT

SEX

WEIGHT

Are you US Citizen? If not Indicate Nationality

PLACE OF BIRTH (City, State and Country)

TYPE OF WORK TO PERFORM (Position/Job Title)

Contract/Work COMPLETION DATE

PART II - EMPLOYMENT INFORMATION (Completed by Prime Contractor)

NAME OF FACILITY and/or DUTY STATION (WLA, Sep…)

GLAHS VA - WLA

CONTRACT Number:

STREET ADDRESS OF FACILITY (for Project)

CITY OF FACILITY/STATION

FACILITY OR ASSIGNED DUTY STATION

ZIP CODE OF FACILITY OR STATION

VA PROJECT No:

VA ENGINEER/COR:

VA PROJECT NAME:

NAME OF FIRM/COMPANY EMPLOYING (Applicants)

WORK PHONE NUMBER (Applicants)

SUPERINTENDENT ON SITE: NAME/PHONE #

SUPERINTENDENT E-MAIL ADDRESS

FIRM PROJECT MANAGER E-MAIL ADDRESS PROJECT MANAGER PHONE #

NAME OF PRIME CONTRACTOR (If same so state)

CONTRACT END DATE

Contractor must enter project information here and on VA_ID Project Registry 4Contractors.xls sheet to tract Schedules and progress of badge status.

FIRST NAME as it appears on valid IDs:

LAST NAME:

HOME PHONE NUMBER or CELL:

HOME STREET ADDRESS USA No PO Box:

HOME CITY:

DATE OF BIRTH:

COLOR OF EYES:

SEX:

Are you US Citizen If not Indicate Nationality:

TYPE OF WORK TO PERFORM PositionJob Title:

FACILITY OR ASSIGNED DUTY STATION:

VA PROJECT No:

VA PROJECT NAME:

NAME OF FIRMCOMPANY EMPLOYING Applicants:

SUPERINTENDENT ON SITE NAMEPHONE:

FIRM PROJECT MANAGER EMAIL ADDRESS:

NAME OF PRIME CONTRACTOR If same so state:

Department of Veterans Affairs

WEST LOS ANGELES MEDICAL CENTER

LOS ANGELES, CA 90073

Medical Center Policy

132-12

IDENTIFICATION BADGES

1. PURPOSE: To establish Medical Center policy concerning the issue, use, and control of identification badges.

2. POLICY: Each employee, physician, work study student, volunteer, vendor, and contractor will wear the identification badge specified herein while at this Medical Center in an official (on-duty) capacity.

a. Photo identification badges will be issued to all regular full-time, regular part-time, temporary, without compensation (WOC)/volunteer employee's and work study students.

b. Identification badges without photographs will be worn by vendors, visitors, (when applicable), and contractors assigned to work short periods of time

3. RESPONSIBILITY:

a. Chief, Police & Security Department is responsible for preparing and issuing the identification badges. Chief, Police and Security Department shall also be responsible for determining if, or when, a numbered identification badge will be issued to a contractor, vendor, patient, or visitor.

b. Employees are responsible for reporting to Police and Security Department, Building

236, during their first week of employment.

c. Community Resource Department is responsible for assuring that volunteers report to

Police & Security Department for badge issuance.

d. Department Chiefs are responsible for:

(1) Ensuring that their employees wear photo identification badges. Individual employees are responsible for wearing their photo identification badges, as well as guarding against loss or theft.

(2) Assuring that vendors who regularly conduct business at the facility report to

Police and Security Department for issuance of an appropriate identification badge. Vendors who intermittently visit the facility are not required to possess or wear an identification badge.

e. Chief, Engineering Department is responsible for submitting requests to Police and

Security Department requesting issuance of identification cards to contractors (short term and long term).

4. PROCEDURES:

a. Badges will be worn in front of the person above the waist, with the photo or badge number clearly displayed at all times.

b. The proper wearing of the identification badge is required while employed and in official capacity (on-duty).

c. Contractors working for extended periods of time will be issued photo identification badges. Those working for short periods of time will issued a non-pictured identification badge.

d. When deemed appropriate, photo identification badges for designated incapacitated patients will be issued.

e. Vendors who regularly conduct business at the Medical Center will be issued a numbered identification badge.

f. Badges are government property and will not be defaced or altered in any manner that would obscure the photograph, Department name, or printed name.

g. Badges are to be returned to Police and Security Department upon termination, separation, or transfer.

h. In the case of inter-department transfers, an employee will be required to report to

Police & Security Department for a new badge, at no cost.

i. If the badge becomes lost or defaced due to employee negligence, a request by the

Service Chief for replacement will be directed to the Chief, Police & Security Department. A replacement fee of $10.00 will be charged to the employee.

5. REFERENCE: M-1, Part VII, Chapter 7, Paragraph B.07c.

6. RESCISSION: Identification Badges, MCPM 132-12, dated 5/96.

7. REVIEW DATE: Review as needed and reissue every three years.

Lynn S. Carrier

Acting Executive Director

*Please note: The original signed copy of this policy is available in the Director of Informatics office, please contact Myrtis Franklin at extension X83724. This policy was signed on June 3,1998.

BUILDING KEY AGREEMENT

The undersigned representative of the Prime Contractor/Engineering firm working for the VA

Greater Los Angeles Healthcare System acknowledges receipt of building key(s) and assures their accountability and return to the Engineering Section at expiration of contract(s).

The undersign individual further assumes responsibility for issuance and recovery of said key(s) for sub-contractors. It is understood that the undersigned further agrees to immediately report to the “Project Engineer” the loss of any issued keys*.

*A $500.00 FEE WILL BE ASSESSED FOR EACH KEY NOT RETURNED.

Prime Contractor Name:

Project Name: __________________________________________________________________

Project/Contract No. & Exp. Date: _________________________________________________

Item Key No. Purpose/Use Quantity Initials

Contractor Name & Position, typed or printed

Signature

Signature of VA COR

Contracting Officer’s Representative (COR)

Prime Contractor Name:

Project Name:

ProjectContract No Exp Date:

Key No1:

PurposeUse1:

Quantity1:

Initials1:

Key No2:

PurposeUse2:

Quantity2:

Initials2:

Key No3:

PurposeUse3:

Contractor Name Position typed or printed:

Quantity3:

Initials3:

VA COR:

Engineering Department System Distribution & Shutdown

UTILITY SYSTEM MAINTENANCE ADVISORY

To be filled out by contractor:

Date: ____________________ Project #___________________________________________

Building #_________________ Room/ Area________________________________________

A shutdown of _______________________________________________________________ is proposed for the following reason(s):

Contractor Contact/Name:________________________________________________________

Affected Building/Area/Room(s) are:_______________________________________________

Affected work area will/may include:

Shut down will start at___________ (time) on_____________ (day of week) ______________(date) and will end by ________________(time) on _____________ (day of week) ______________(date)

To be filled out by VA COR on receiving request by contractor

Requested by: Service___________________ Signature ___________ _________

Concurrence: Service___________________ Signature ___________ _________

Notification/ Concurrence Service ___________________ Signature ___________ _________

Notification/ Concurrence Service ___________________ Signature ___________ _________

Notification/ Concurrence Service ___________________ Signature ___________ _________

Comments surrounding maintenance activity (to be completed by 138F)

Date:

Project:

Building:

Room Area:

A shutdown of:

is proposed for the following reasons 1:

is proposed for the following reasons 2:

Contractor ContactName:

Affected BuildingAreaRooms are:

Affected work area willmay include 1:

Affected work area willmay include 2:

Shut down will start at:

time on:

day of week:

and will end by:

time on_2:

day of week_2:

Service_4:

Service_5:

Comments surrounding maintenance activity to be completed by 138F:

Occupational Health and Safety:

Facilities: Facilities

Engineering Services: Engineering Services

07/2016

Fire Watch VA Greater Los Angeles Healthcare System

Project Name_____________________________________________________________________________

Building and Location:______________________________________________________________________

Date of Fire Watch:_________________________________________________________________________

Duration of Fire Watch: _______ hours. From: _____________ To________________

Name of Contractor’s representative conducting fire watch:__________________________________________

1. A fire watch will be established and maintained until such time that the fire protection equipment or systems are restored to service. The fire watch shall have the responsibility for the continuous patrol of the entire area for the purpose of detecting fires and transmitting an immediate alarm to the fire number and notification of building occupants. This form must be filled out daily and for each 12 hours, or for each shift conducting the watch.

2. Walk-through will be conducted every Hour by the Fire Watch. Please indicate date and time. Use multiple forms for multiple days:

PLEASE PRINT

Date:

Time: Time: Time:

3. Fire Watch shall adhere to the following requirements:

a. Continuously and completely patrol all areas within the building.

b. If a fire is discovered, immediately implement the RACE acronym.

R escue personnel within the immediate area A larm activate pull station and dial “12” from a VA phone.

C ontain by closing all doors E vacuate

c. Maintain a log to record the time of completion of each patrol and all other significant information. Log shall be maintained on the premises and available for inspection by the Fire Department.

d. Relay any special orders or pertinent information to their relief.

e. Remain on duty until relieved.

f. If Fire Watch is discontinued for any reason, notify the Safety Office at ex. 83563 or after-hours

44988. (Pager # 5005)

4. Fire Watch/Building Occupants will be notified when the fire protection equipment or systems are restored to service. If you have any questions and/or concerns contact ext. 83563 or dial pager # 5005.

Contractor’s signature:____________________________________________

Project Name:

Building and Location:

Date of Fire Watch:

Duration of Fire Watch:

From:

To:

Name of Contractors representative conducting fire watch:

Date:

Time:

Time_2:

Time_3:

Time_4:

Time_5:

Time_6:

Time_7:

Time_8:

Time_9:

Time_10:

Time_11:

Time_12:

Time_13:

Time_14:

Time_15:

Time_16:

Time_17:

Time_18:

am/pm: [am]

D. Construction Fire Safety Checklist.doc

Project No. 691 - _ _ - _ _ _ _ Date _ _ / _ _ / _ _ _ _

CONSTRUCTION FIRE SAFETY CHECKLIST

(FOR PROTECTION OF VA PROPERTY, PATIENTS, VISITORS AND PERSONNEL)

Contractor to fill out checklist and provide to COR, daily or weekly, verify with COR.

Construction Safety Inspection may take place without notice any time during construction

a. Fire extinguishers (OSHA 1926.150 [c])

_____ (1) Extinguisher available within 100 feet. Extinguisher rated not less than 2A.

_____ (2) If flammable liquids or gases present, a fire extinguisher rated not less than 10B within

50 feet.

b. Ignition hazards (OSHA 1926.151 [a])

_____ (1) Internal combustion engines located away from combustibles.

_____ (2) Smoking is prohibited in fire hazard areas (flammables, combustibles).

c. Indoor storage (OSHA 1926.151 [d])

_____ (1) Site kept free from accumulation of unnecessary combustibles.

_____ (2) Storage shall not obstruct means of exits.

_____ (3) Clearance maintained around lights and heating units.

d. Flammable and combustible liquids (OSHA 1926.152)

_____ (1) Approved containers.

_____ (2) No storage in areas of exist, stairways or people traffic areas.

_____ (3) Max. 25 gal. in a room otherwise approved storage cabinet.

e. Temporary heating devices (OSHA 1926.154)

_____ (1) Adequate ventilation for workmen and heater combustion.

_____ (2) Clearance of combustibles from heaters (3-foot minimum).

_____ (3) Stability of heaters.

f. Signs and barricades (OSHA 1926.200)

_____ (1) Danger signs where immediate hazard exists.

_____ (2) Caution signs where potential hazard exists.

_____ (3) Safety instruction signs where necessary.

_____ (4) Barricades where necessary to protect persons from hazards.

g. Welding and cutting – Hot work permit required (NFPA-51B and OSHA 1910.252)

_____ (1) Inspection of area before permit given.

_____ (2) Distance from combustibles 35 feet.

_____ (3) Fire extinguisher in immediate area.

_____ (4) Wall and floor openings covered.

_____ (5) No flammable liquids present.

_____ (6)Inspection after work.

h. Electrical (OSHA 1924.400-2, 1926.302 and NFPA 241-4)

_____ (1) All temporary wiring grounded and in accordance with National Electric Code.

_____ (2) Precautions taken to make and open wiring inaccessible to other than authorized personnel.

_____ (3) Temporary lighting bulbs equipped with guards, use heavy duty cords, and not suspended by their cords unless specifically designed for that use.

_____ (4) Run of open conductors located away from possible damage and fastened at intervals of no greater than 10 ft.

_____ (5) Outlets in construction sites have GPCI or assured equipment grounding.

_____ (6) Extension cords protected from damage. No worn or frayed cables. Not hung from nails or suspended by wire.

_____ (7) Fuse or circuit breaker provided for each feeder or branch circuit.

_____ (8) Electrical powered operated hand tools shall either be of the approved double insulated

D. Construction Fire Safety Checklist.doc type or property grounded.

i. Demolition (OSHA 1926.850-858 and NFPA 241, Ch 7)

_____ (1) Electric, gas, water, steam, etc.. shut off prior to work.

_____ (2) Any utilities that are necessary to be maintained need protection.

_____ (3) Masonry walls shall not be permitted to tall on floors such that it would exceed the safe carrying capacity of the floor.

_____ (4) Floor openings within 10 feet of any wall being demolished shall be planked solid except when no one below.

_____ (5) The storage of waste material and debris shall not exceed the floor-loading limit.

_____ (6) Construction of dust barriers as needed. (Not OSHA)

_____ (7) Notification to shut off and protect smoke detectors, etc. during daytime only. (Not

OSHA)

_____ (8) Precautions if floors are soaked with oil or flammable liquids, if dust accumulation is present or other combustibles are present and hot work is being performed.

_____ (9) Smoke is prohibited throughout demolition (NFPA 241.7-4.2).

_____ (10) Flammable and combustible liquids removed from area.

_____ (11) Water supplies must still be available from fire hydrants in the vicinity of the structure or area.

_____ (12) Asbestos abatement, breakables (i.e.. glass) shall be removed prior to demolition.

j. Temporary buildings, trailers (NFPA 241. Ch 2)

_____ (1) Temporary offices, trailer, sheds, etc.. of combustible construction at least 30 feet from permanent buildings.

_____ (2) Only safety installed approved heating devices used. Ample clearance around stoves, heaters and chimneys per HFPA 211.

k. Roofing operations (NFPA 241, Ch 6)

_____ (1) Asphalt and tar kettles located outside the building or on a non-combustible root away from combustibles. Kettles must have gravity lids, tight fitting.

_____ (2) Torch applied roofing systems shall be installed using extreme caution. Follow manufacturers instructions. Caution around roof openings, penetrations or flashings.

_____ (3) Fire extinguisher. 20-B minimum, within 30 ft. of roof kettle. At least one extinguisher 2A:20-B:C on the roof being repaired: also one within 30 ft. of torch applied roofing equipment.

_____ (4) Fuel containers at least 10 feet away from burner flame.

_____ (5) Notify building occupants who might be affected.

_____ (6) Investigate location of supply air intakes. Coordinate shutdowns as necessary.

_____ (7) Root edges will be guarded by means of typical roof protection or a safety monitoring system.

l. Exit pathways (NFPA 241, Ch 5; also reference to HFPA 101)

_____ (1) Every building and area will remain accessible to fire department apparatus and personnel. Roadways will be maintained with 20 ft. of all buildings.

_____ (2) Adequate egress paths including stairs and corridors will be maintained at all times.

Exits may only be blocked temporarily if unavoidable and when adequate alternate measures are provided (signage, temporary fire detection, training, etc.) to warn personnel.

Superintendent

1 Extinguisher available within 100 feet Extinguisher rated not less than 2A:

2 If flammable liquids or gases present a fire extinguisher rated not less than 10B within:

1 Internal combustion engines located away from combustibles:

2 Smoking is prohibited in fire hazard areas flammables combustibles:

1 Site kept free from accumulation of unnecessary combustibles:

2 Storage shall not obstruct means of exits:

3 Clearance maintained around lights and heating units:

1 Approved containers:

2 No storage in areas of exist stairways or people traffic areas:

3 Max 25 gal in a room otherwise approved storage cabinet:

1 Adequate ventilation for workmen and heater combustion:

2 Clearance of combustibles from heaters 3foot minimum:

3 Stability of heaters:

1 Danger signs where immediate hazard exists:

2 Caution signs where potential hazard exists:

3 Safety instruction signs where necessary:

4 Barricades where necessary to protect persons from hazards:

1 Inspection of area before permit given:

2 Distance from combustibles 35 feet:

3 Fire extinguisher in immediate area:

4 Wall and floor openings covered:

5 No flammable liquids present:

6Inspection after work:

1 All temporary wiring grounded and in accordance with National Electric Code:

2 Precautions taken to make and open wiring inaccessible to other than authorized:

3 Temporary lighting bulbs equipped with guards use heavy duty cords and not:

4 Run of open conductors located away from possible damage and fastened at intervals of:

5 Outlets in construction sites have GPCI or assured equipment grounding:

6 Extension cords protected from damage No worn or frayed cables Not hung from:

7 Fuse or circuit breaker provided for each feeder or branch circuit:

8 Electrical powered operated hand tools shall either be of the approved double insulated:

1 Electric gas water steam etc shut off prior to work:

2 Any utilities that are necessary to be maintained need protection:

3 Masonry walls shall not be permitted to tall on floors such that it would exceed the:

4 Floor openings within 10 feet of any wall being demolished shall be planked solid:

5 The storage of waste material and debris shall not exceed the floorloading limit:

6 Construction of dust barriers as needed Not OSHA:

7 Notification to shut off and protect smoke detectors etc during daytime only Not:

8 Precautions if floors are soaked with oil or flammable liquids if dust accumulation is:

9:

10 Flammable and combustible liquids removed from area:

11 Water supplies must still be available from fire hydrants in the vicinity of the structure:

12 Asbestos abatement breakables ie glass shall be removed prior to demolition:

1 Temporary offices trailer sheds etc of combustible construction at least 30 feet from:

2 Only safety installed approved heating devices used Ample clearance around stoves:

1 Asphalt and tar kettles located outside the building or on a noncombustible root away:

2 Torch applied roofing systems shall be installed using extreme caution Follow:

3 Fire extinguisher 20B minimum within 30 ft of roof kettle At least one:

4 Fuel containers at least 10 feet away from burner flame:

5 Notify building occupants who might be affected:

6 Investigate location of supply air intakes Coordinate shutdowns as necessary:

7 Root edges will be guarded by means of typical roof protection or a safety monitoring:

1 Every building and area will remain accessible to fire department apparatus and:

2 Adequate egress paths including stairs and corridors will be maintained at all times:

Superintendent:

date:

project#:

DAILY LOG - FORMAL CONTRACT

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of t

Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a vali OMB number. We anticipate that the time expended by all individuals who must complete this form will average 12 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form

CONTRACTOR:

WEATHER CONTRACT NO

DATE 7 A.M. VA ###-C-####

2/18/2009 TEMPER- PROJECT NO.

Wednesday ATURE

3:30 P.M. 691-YY-###WL

BRANCH SKILLED WORKERS UNSKILLED LOCATION AND

OF WORK AND HELPERS WORKERS DESCRIPTION OF WORK

US CONSTRUCTION Hrs.

Bill Clinton Electrician 8.0

Herman Monster Electrician 8.0

Juan Bond Labor 16.5

TOTAL 0 16.0 16.5

EQUIPMENT FORCE DELIVERY OF MATERIAL

SATISFACTORY

UNSATISFACTORY

REMARKS (Continue on reverse, if necessary)

11.05am Jon L. came in to check on new HVAC installations.

He said servicing platforms are required for the ceiling AC equipments.

VA FORM EXISTING STOCKS OF VA FORM 10-6131, OCT 1989,

DEC 1998 (R) 10-6131 WILL BE USED

SAMPLE - WORK PROGGRESS DETAILS

US CONSTRUCTION

07:00am George with US Construction, Super on site to check on set up for demolition works.

08:00am US Construction continue demolish ceiling & walls.

09:00am US Construction continue demolish ceiling & walls.

09:30am Start to dump the wastes from demolition.

10.30am Finish demolition & continue dumping & cleaning.

11.00am Finish wall & ceiling demolition,dumping & cleaning.

We inform Roger Moore to write a RFI to Project Engineer for these platforms.

11.30am Jon call Tom about framing the platform on Tuesday.

SIGNATURE OF RESIDENT ENGINEER CONTRACTOR/SUPERINTENDENT:

Fabrication of XYZ for installation of 00" conduit

Install XYZ for 00" conduit run in XYZ FLOOR of build. 000

Help to install XYZ. Infection control and demo walls in bathroom build. 000

VAMC, 11301 Wilshire Bulevard, West Los Angeles, CA 90073

PROJECT TITLE:

691-YY-1##WL, CONSTRUCTION PROJECT Phase X XYZ Construction Conmpany

E. Daily Log- VA Reports Construction n F_Safety forms.xlsx

STATION: DATE:

PHONE NUMBER: PROJECT NUMBER:

BUILDING/ROOM:

1 Means of egress is clear in construction and adjacent areas. YES NO N/A

2 Access for the fire department and emergency services is clear. YES NO N/A

3 Fire sprinkler system is active. YES NO N/A

4 Fire alarm system is active. YES NO N/A

5 Smoke detectors are active. YES NO N/A

6 Temporary systems are in place. YES NO N/A

7 Construction…