Energized Electrical Work Permit - Local

• Issuance Date and Time

  Date

• Expiration Date and Time

  Date

• Voltage of Work

  Select 120 208 240 277 460 480

  • 120
  • 208
  • 240
  • 277
  • 460
  • 480
• Work Location
  Address

• Document No.

• Client / Site

• Prepared by

• Personnel

ANSWER THE FOLLOWING

• Have all affected personnel in the area been notified of the energized electrical work?

  Yes

  No

  N/A

• Have all circuits been disconnected that can possibly be disconnected?

  Yes

  No

  N/A

• Will protective gloves and sleeves be used?

  Yes

  No

  N/A

• Have they been inspected?

  yes

  no

• Have all energized lines been insulated or covered with protective covering that can be?

  Yes

  No

  N/A

• Will protective gloves and sleeves be used? <br><br><br><br>

  Yes

  No

  N/A

• Have they been inspected and determined in good condition for the work to be performed?

  yes

  no

• Are ladders that are going to be used of the non conductive type?

  Yes

  No

  N/A

• Have this ladders been inspected?

  Yes

  No

  N/A

• What type of platform will be used to work

  scissor lift

  Boom lift

  Baker scaffold

  other

• What type of platform

• Is there a second person on the job?

  yes

  no

• Is that person CPR/ First aid trained?

  yes

  no

• Is lockout/tagout required and used?

  yes

  no

• Has procedure been followed

  yes

  no

• Why not?

• Are all flammables removed from the area

  Yes

  No

  N/A

• Why not

  Media

• Has a JSA been completed

  yes

  no

The above items had been checked and the area is considered to be safe to proceed with the energized electrical work described above.

• Job Superintendent

  Sign

• Project Manager

  Sign

• Health and Safety Manager

  Sign

Work has been completed and equipment is back to normal. Permit is removed from the field.

• Job Superintendent

  Sign

• Health and Safety Manager

  Sign

Job Safety Analysis

• Prepared by

• Approved by

  PM via Phone

  Safety Director via phone

  PM

  Safety Director

  President

• SEQUENCE OF JOB STEPS

• POTENTIAL HAZARDS

  Select arc flash, arc blast electrocution falls other

  • arc flash, arc blast electrocution
  • falls
  • other

• Please explain

• Required PPE

  class 0

  Class 1

  Class2

  Class3

  Other

• Recommended Action or Procedure to eliminate potential hazards