Title Page
-
FSSW Hot Work Permit
I-5 North Coast Corridor Project
JOB #: 3179 -
Prepared by:
-
Conducted on
-
Segment:
- Segment 1
- Segment 2
- Segment 3
- Segment 4
- Segment 6
- Segment 7
-
Work Area:
-
START DATE & TIME
-
EXPIRE DATE & TIME
-
Is this a daily operation?
CONTACTS:
-
Eric Johnson
FSSW Safety Manager
Phone: 760-504-7159 -
Project Supervisor and other Contacts
Contact
-
Name:
-
Position
-
Phone:
DESCRIPTION OF WORK
-
Describe work to be performed:
-
Specify Equipment do be used
- Oxy / Acetylen
- Air Arc / Gouging
- Electric Arc
- Other
-
OTHER:
HAZARD EVALUATION or ASSESSMENT
-
Fire Hazards Present
Fire Hazard
-
Describe Fire Hazard:
-
Describe Controls Implemented
-
Other Hazards:
Hazard
-
Describe Hazard:
-
Describe Controls Implemented
-
Is the work area a Confined Space?
-
Work must also comply with Confined Space Policy in IIPP Manual. You must complete a confined space checklist in addition to this checklist.
PERSONNEL INVOLVED:
-
Authorized Welders
Welder
-
Authorized Welder name and Signature
-
License Review:
-
Expiration Date:
-
Equipment Authorized to use:
- Oxy / Acetylen
- Air Arc / Gouging
- Electric Arc
- Other
-
IMPORTANT!! Fire watch must remain 1/2 hour after task with emergency communication system with supervisor in place.
-
Workers / Fire Watch
Worker
-
Name and Signature
-
START Time
-
STOP Time
PERMIT STATUS
-
Permit Acceptance
-
Reason for Rejection
PHOTOS
-
Any Relevant Photos
Photos
-
Description
-
Photo
AUTHORIZATION:
-
I verify the above location has been examined PRIOR to the START of the task including FIRE hazard assessment, FALL hazard assessment and all other hazard assessments identified above. I confirm that prevention controls and emergency communication systems are in place, and that permission is granted for this operation.
-
Inspected By:
Person
-
Signature:
-
Select date
