IX Engineering Survey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Name of the building/ structure:

• Date built:

• Description:

Dimensions

• Length

• Width

• Height

Materials

• Foundation:

• Walls:

• Floors:

• Method of demolition:

• Underground utility location confirmation #:

• Potential hazards ( collapse, structural failure, etc.):

• Item #s requiring a Job Safety Analysis:

• Item #s requiring Professional Engineer input:

Safety Exposures

• Oxygen lines

  Yes

  No

• Natural gas lines

  Yes

  No

• Electrical lines

  Yes

  No

• Water lines

  Yes

  No

• Other utilities

  Yes

  No

• Fire hazards

  Yes

  No

• Adjacent walkways

  Yes

  No

• Adjacent roadways

  Yes

  No

• Adjacent buildings

  Yes

  No

• Combustibles

  Yes

  No

• Water towers

  Yes

  No

• Railroad tracks and crossings

  Yes

  No

• Heavy equipment hazards

  Yes

  No

• Confined space hazards

  Yes

  No

• Smoke stacks<br>

  Yes

  No

• Elevators

  Yes

  No

• Party walls

  Yes

  No

• Basement

  Yes

  No

• Open pits or trenches

  Yes

  No

• Bulkheads

  Yes

  No

• Manholes to preserve

  Yes

  No

• SDS (MSDS) provided

  Yes

  No

• Fall hazards

  Yes

  No

• Lead exposure

  Yes

  No

• Chemical exposure

  Yes

  No

• Process hazards

  Yes

  No

• Live utilities

  Yes

  No

• Utilities to disable

  Yes

  No

• Lighting

  Yes

  No

• Fiber optic cables

  Yes

  No

• Trenching/ Excavating

  Yes

  No

• Shoring required

  Yes

  No

• Pre-existing structural damage

  Yes

  No

• Asbestos

  Yes

  No

• Environmental issues

  Yes

  No

• Other safety issues