FENJ Energized Electrical Work Permit

• Document No.

• Audit Title

• Job name and number

• Conducted on

  Date

• Prepared by

• Location
  Address

Part 1: To be completed by the requester

• Requester/ Title

• Description of circuit/ equipment/ location

• Description of work to be done

• Justification of why the circuit/ equipment can't be de-energized

Part 2: To be completed by the electrically qualified persons doing the work

• Detailed job description procedure to be used in preforming the work

• Describe the safe work practices to be employed

• Results of the shock hazard analysis

• Limited approach boundary (in feet) using Table 130.4(D)(a)

• Restricted approach boundary (in feet) using Table 130.4(D)(a)

• What is the necessary shock PPE required to safely preform the assigned task

  Yes

  No

  N/A