SHBRH MM 300.25 Attachment A- Construction/Renovation Permit

• Conducted on

  Date

• Prepared by

PROJECT INFORMATION

• Name of Project

• Location

• Start Date

  Date

• Estimated Completion Date

  Date

• SHBRH Project Coordinator

• Name of Contractor Performing Work

• 24 Hour Contact Number

INFECTION CONTROL RISK LEVEL

• Select The Risk Level (NOTE: You must refer to the matrix included in the policy)

  Level 1

  Level 2

  Level 3

  Level 4

PENETRATIONS

• Note: NFPA 101-2000:18/19.3.7.3- all penetrations must be sealed with a fire rated sealer

• Is this project creating any penetrations?

  Yes

  No

  N/A

HOT WORK

• A "Hot Work Permit" will be required if the project is involving open flames or producing heat and/or sparks. This includes, but not limited to: brazing, cutting, grinding, soldering, torch-applies roofing and welding.

• Does this project require a "Hot Work Permit"

  Yes

  No

  N/A

PERSONNEL ONSITE

• Please list all sub-contractors (company name and phone number)

• Please list the names of ALL personnel that will be onsite. Refer to the identification policy of MCMC

PROJECT SPECIFIC ADDITIONAL REQUIREMENTS

FINAL STEP

• This permit must be completed prior to the start of the project. This permit will be posted at the entrances of the work site.

• Please select today's date.

  Date

• Please sign your name as the project manager.

  Sign

• Email this permit to: construction@mcmcbr.com