Disconnection of existing services

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

PROJECT:

• Project

• Location on site

• Client

• Client representative

VERIFICATION

• Construction drawings approved for use

  Yes

  No

  N/A

• DRWG No

• REV No

Services have been identified

• 2. Services have been identified

• Notification of service disruptions are in place

  Yes

  No

  N/A

SERVICES TO BE DISCONNECTED

• Potable cold water service

  Yes

  No

  N/A

• Hot water service

  Yes

  No

  N/A

• Warm water service

  Yes

  No

  N/A

• Hot water return

  Yes

  No

  N/A

• Fire hydrant service

  Yes

  No

  N/A

• Fire hose reel service

  Yes

  No

  N/A

• Gas service

  Yes

  No

  N/A

• Sanitary drainage service

  Yes

  No

  N/A

• Trade waste service

  Yes

  No

  N/A

• Stormwater service

  Yes

  No

  N/A

Existing pipework

• Live pipe work protected and clearly marked

  Yes

  No

  N/A

• redundant pipe work removed from area

  Yes

  No

  N/A

• In ground drainage capped in ground

  Yes

  No

  N/A

• In ground drainage capped at floor level

  Yes

  No

  N/A

SIGNATURE: DATE:

• CHECKED BY:

• REVIEWED BY

• DATE:

  Date