Special Work Permit Form.pdf
PDF 171 KB Posted
- Solicitation number
- 69056722B000015
About this file
This document is a Bureau of Reclamation special work permit form. The form is used to authorize contractors to perform work and requires signatures from the contractor's workplace representative, a Bureau worksite representative, and an authorized Bureau employee. The contractor must provide their name, the special work permit and clearance numbers, and a description of the work to be performed. The form also documents whether personal protective grounds will be required. Upon completion of the work, the contractor and Bureau representatives must sign to confirm the work is finished and all equipment is cleared from the work area.
The related federal contract opportunity is a solicitation from the Department of Transportation Federal Highway Administration to improve the dam crest road at Lake Cascades in Idaho. The solicitation is full and open with no additional details provided on required products or services, response dates, or other contract specifics.
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POM-215 (08-2018) Bureau of Reclamation
SPECIAL WORK PERMIT
Page of .\DOI_Seal_Forms_test.jpg POM-215 (08-2018) Bureau of Reclamation Page of POM-215 (08-2018) Bureau of Reclamation Page of Contractor Name:
SWP#
CL#
HLO#
Purpose and Scope of Work to be Performed: (Attach Additional Sheets if Needed) Describe market value information e.g., quotes, catalogs, internet product search, GSA, etc.
Will this SWP require personal protective grounds?
The contractor is authorized to proceed with the work as designated above. Signature indicates that the undersigned have discussed the work to be performed, reviewed the details of the Clearance or HLO for adequacy, and verified understanding of the placement of shorts, jumpers, and personal protective grounds and conditions of the working area.
ALL SIGNATURES ARE REQUIRED.
Authorized Reclamation Employee (Print Name) (Signature) Contractor's Workplace Representative (Print Name) (Signature) Reclamation Representative (Print Name) (Signature) This Special Work Permit issued at the worksite:
Date Time Release of Special Work Permit Describe market value information e.g., quotes, catalogs, internet product search, GSA, etc.
Signature certified that the contractors work under the clearance is complete, that all shorts, jumpers, and personal protective grounds are removed or accounted for, and all contractor personnel and equipment are clear of the work area covered by this Special Work Permit.
ALL SIGNATURES ARE REQUIRED.
Contractor's Workplace Representative (Print Name) (Signature) Reclamation Representative (Print Name) (Signature) Authorized Reclamation Employee (Print Name) (Signature) This Special Work Permit issued at the worksite:
Date Time 10.0.2.20120224.1.869952.867557
| CurrentPage: |
| PageCount: |
| Contractor Name: |
| Special Work Permit Number: |
| Clearance Number: |
| Hot Line Order Number: |
| Purpose and scope of work to be performed: |
| No, this Special Work Permit will not require personal protective grounds. : 0 |
| Yes, this Special Work Permit will require personal protective grounds. : 0 |
| Bureau Clearance or Hot Line Order Holder's Name: |
| Bureau Clearance or Hot Line Order Holder's Signature: |
| Contractor's Workplace Representative's Name: |
| Contractor's Workplace Representative's Signature: |
| Bureau Worksite Representative's Name: |
| Bureau Worksite Representative's Signature: |
| Date Special Work Permit issued at the worksite: |
| Time Special Work Permit issued at the worksite: |
| Name of Contractor's Workplace Representative for release of Special Work Permit: |
| Signature of Contractor's Workplace Representative for release of Special Work Permit: |
| Name of Bureau Worksite Representative for release of Special Work Permit: |
| Signature of Bureau Worksite Representative for release of Special Work Permit: |
| Name of Bureau Clearance or Hot Line Order Holder for release of Special Work Permit: |
| Signature of Bureau Clearance or Hot Line Order Holder for release of Special Work Permit: |
| Date Special Work Permit issued at the worksite: |
| Time Special Work Permit issued at the worksite: |
File details come from the government source that posted it. Updated .