Excavation_Permit.pdf

APPENDIX A

EXCAVATION PERMIT

(Proponent Agency is Engineering Services Division)

(TEAD-R 420-16)

TOFROMPERMIT EFFECTIVE DATE

PHONEEXCAVATION REQUEST BY

LOCATION OF EXCAVATION

PURPOSE OF EXCAVATION

BASED UPON DRAWINGS AVAILABLE, AND PERSONAL KNOWLEDGE OF THE AREA FOR WHICH I AM

RESPONSIBLE, THE SITE IS FREE OF UNDERGROUND FACILITIES OR SYSTEMS EXCEPT AS NOTED. IF

YES IS CHECKED THE CONTRACTOR IS REQUIRED TO NOTIFY THE UNDERSIGNED 24 HOURS IN

ADVANCE OF EXCAVATION.

NOTIFICATION

REQUIRED

YES NO

FACILITY SUPPORT DIVISION - BLDG 502,(435) 833-2603

ELECTRICAL - BLDG 502,(435) 833-2603

WATER - BLDG 502, (435) 833-2603

TELEPHONE CONTRACTOR - BLDG 10,(435) 833-3201/2000

ENVIRONMENTAL OFFICE - BLDG 8,(435) 833-2761

SAFETY OFFICE - BLDG 9,(435) 833-3888

NOYES Confirmation NumberBLUE STAKES Notification Required If ''yes'' is checked privately owned utilities exist in the excavation area. In addition to notifying the required Government organizations listed above, the Excavator is required to notify BLUE STAKES (801) 983-1555, and coordinate marking of utilities by BLUE STAKES, and the Government in the excavation area. This permit is not valid if yes is checked and the confirmation number is missing.

ENGINEERING SERVICES DIVISION CHIEF OR CONTRACTING

OFFICERS REPRESENTATIVE (COR) - BLDG 501 OR FOR IN-HOUSE

PROJECTS FACILITY SUPPORT DIVISION REPRESENTATIVE

NOTE: THIS PERMIT IS TO BE COMPLETED AND ATTACHED TO THE WORK ORDER PRIOR TO THE WORK

ORDER BEING ISSUED.

AFTER HOUR EMERGENCIES? CALL (435) 833-2911 OR (435) 833-2015

EXCAVATOR MUST HAVE A VALID PERMIT IN POSSESSION BEFORE/DURING EXCAVATION

COMMENTS

TEAD FORM 2782-R REV 13 MAY 09 (Previous editions obsolete)

EXCAVATOR IS RESPONSIBLE TO MAINTAIN ALL UTILITY MARKINGS AND IS LIABLE FOR ANY

DAMAGE CAUSED THROUGH THE FAILURE TO MAINTAIN MARKINGS