FENJ Energized Electrical Work Permit Rev 1

• 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

• Requester/Title

• Date

  Date

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

• Voltage to which personnel will be exposed

  Select 120/208 277/480 5KV 15Kv 26KV 32KV

  • 120/208
  • 277/480
  • 5KV
  • 15Kv
  • 26KV
  • 32KV

• Results of the shock hazard analysis

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

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

• Necessary shock, personal and other protective equipment to safety perform assigned task

• Results of the arc flash risk assessment

• Available incident energy at the working distance or arc flash PPE category

• Necessary shock, personal and other protective equipment to safety perform assigned task

• Arc flash boundary

• Means employed to restrict the access of unqualified persons from the work area

• Evidence of completion of a job briefing, including discussion of any job-related hazards

• Do you agree the above described work can be done safely?

  YES

  NO

• Speak to the requester about the possibility of not working energized, or not preforming the work. DO NOT do the above work unless you understand the hazards and are comfortable

• Electrically Qualified Person(s)

  Sign

• Date

  Date

• Electrically Qualified Person(s)

  Sign

• Date

  Date

Part 3 Approval(s) to preform the work while electrically energized

• GC/CM

  Sign

• Safety Manager

  Sign

• Superintendent

  Sign

• Owners Accountable Representative

  Sign

• Electrically Knowledgeable Person

  Sign

• Date

  Date