VA 01 00 00 General Requirements - Attachment 5a and 5b.pdf

Attachments 5a & 5b

Contractor Work Plan & Peer Review

SECTION 01 00 00

GENERAL REQUIREMENTS

ATTACHMENT #5 - A

CONTRACTOR WORK PLAN / PEER REVIEW REQUEST

PROJECT No. & TITLE:

DESCRIPTION OF WORK:

TOOLS & EQUIPMENT TO PERFORM WORK:

PERSONAL PROTECTIVE EQUIPMENT FOR WORK:

NAME(S) OF EMPLOYEE(S) PERFORMING WORK:

SUPERVISOR / WORK LEADER NAME (PRINTED):

SUPERVISOR / WORK LEADER SIGNATURE:

DATE:

Section 01 00 00, General Requirements – Attachment #5 - A

Revised Mar 2019

Su M T W Th F Sa DATE: @ TIME: START DATE:

END DATE: DATE: @ TIME:

ESTIMATED DURATION OF WORK:

LOCATION OF WORK:

HOURS

ARC CAL: PPE LEVEL 1 2 3 4

Su M T W Th F Sa

PROCEDURE(S):

All maintenance and repair work must have a written procedure prepared by the maintenance person performing the task.

BEFORE:

DURING:

AFTER:

Section 01 00 00, General Requirements – Attachment #5 - A

Revised Mar 2019

DATE AND TIME COR NOTIFIED:

GENERAL CONTRACTOR’S NOTIFYING PERSON:

NOTIFYING PERSON’S SIGNATURE:

GENERAL CONTRACTOR COMPANY:

PHONE NUMBER(S) –

OFFICE:

CELL:

Section 01 00 00, General Requirements – Attachment #5 - A

SECTION 01 00 00

GENERAL REQUIREMENTS

PEER REVIEW #5 – B

PROJECT No. & TITLE:

* - Designates signature required.

Section 01 00 00, General Requirements – Attachment #5 – B

Revised Mar 2019

Name Signature Title / Service Date

*COR / FMS

*Elec Supv / FMS

*AC Supv / FMS

*Plumb Supv / FMS

*CEP / FMS

*M&O Supv / FMS

*Projects Supv / FMS

*Safety / FMS

*BioMed / FMS

*Chief / FMS

*Infect Ctrl / MED

*Logistics

*SPD/SPS

*Police

*AFGE

*NNU

Power Plant / FMS

*OI&T

Section 01 00 00, General Requirements – Attachment #5 – B

Revised Mar 2019

AREA IMPACTED REPRESENTRATIVE SIGN OFF / MEETING SIGN IN SHEET

PROJECT No. & TITLE:

MEETING DAY/DATE/TIME:

PLEASE PRINT AND SIGN YOUR NAME

AND PROVIDE BEST CONTACT INFO:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Print Name: Signature:

Dept/Company: Phone/Ext:

Check all that apply:

Notification of Live Electrical Work Mitigation Plan

Enclosed Space Permit Contingency Plan

Burn Permit (Hot Work) Utility Shutdown required?

Safety Review (ILSM) Coordination Meeting Required?

Infection Controls Review (ICRA) Utility Shutdown / Closure Notice

Above Ceiling Permit Utility Shutdown & Start Up Procedures

Drawings Enclosed Shutdown Checklist and Flow Chart

RESET PRINT

Section 01 00 00, General Requirements – Attachment #5 - B