Permit Request • CampusOptics

BEFORE STARTING, consider less hazardous work methods or work off site.

If hot work is performed outside of a designated area, USE THIS PERMIT.

See Hot Work Guidance Document for additional information on fire impairments, fire watch, and fire monitoring durations.

If you have any questions or need assistance completing this permit request, contact ehs@csn.edu.

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

General Information

Department* Required

Work Order No.* Required

Work Description* Required

Work Area Risk Assessment

a. Automatic sprinklers are fully operational (see guidance document link at top of page)* Required

b. Hot work equipment is functional, secure and in good repair* Required

c. First Aid and Fire extinguisher are operable and available* Required

Within 35 ft (10m) of the work area:

1) Remove ignitable liquids, combustible dust/lint, and combustible residues (floors and overhead)* Required

2) Remove combustible materials or cover with fire resistant pads, blankets, or curtains* Required

3) Protect floor and wall openings against spread of sparks or embers* Required

4) Shut down ventilation and conveying systems* Required

For Hot Work on/in enclosed equipment, ductwork,or piping, Complete this section

1) Ventilation is adequate

2) Isolate equipment from service and purge flammable vapors

3) Purging and ventilation is verified with gas detector

4) Thoroughly clean equipment to remove all flammables and combustibles

Fire Watch and Fire Monitoring

a. Fire watch to be provided continuous during and after hot work * Required

1) Duration of fire watch post-work (hours) [see guidance document link at top of page]* Required

2) Duration of fire monitoring post-work (hours) [see guidance document link at top of page]* Required

Additional Precautions

Hot Work Performer (Worker)

Name* Required

Affiliation* Required

Fire Watch Attendant

Name* Required

Hot Work Operations Supervisor

Name* Required

Certification

I certify that the Hot Work Performer, Fire Watch Attendant (if applicable), and Hot Work Supervisor acknowledge this permit request and will ensure all permit conditions are met prior to the start of hot work.* Required

Name of Person Certifying Permit Request * Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files