UNIVERSITY OF NORTH DAKOTA SAFE WORK PERMIT FORM 220A |
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Check all blocks that will pertain to the job:
□ Hot Work □ Confined Space Entry (Permit-Required Confined Space requires Confined Space Entry Permit) □ Electrical Lockout/Tagout □ Mechanical Lockout/Tagout □ Backup Person Required □ Other (state): |
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Protective Equipment Check all that apply:
HandsFeet and LegsHeadRespiratorOther □ Leather□ Safety Toe Boots□ Safety Glasses□ Half Face□ Coveralls (cloth) □ Rubberized□ Leggings□ Chemical Goggles□ Full Face□ Coveralls (chemical resistive) □ Thermal□ Chaps□ Ear Protection□ Face Shield□ Thermal Suit □ Latex□ Other (state):□ Hard Hat□ Airline□ Safety Belt □ Other (state): □ Dust Mask□ SCBA□ Body Harness □ Other (state):□ Other (state):□ Life Line □ Other (state):
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Atmospheric Testing Atmospheric testing is required: □ Yes □ No When testing is required, results of the testing will be annotated below: |
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Hot Work
Precautions□ Sprinklers are in service □ Cutting, welding, and grinding equipment are in good repair Area within 35 Feet of the Work□ Floors have been swept clean of combustibles □ Combustible floors have been wet down, covered with damp sand, metal, or other shields □ Combustible material, flammable liquids, vapors, or gases removed or protected □ Wall and floor openings are protected □ Equipment, wiring, piping, and personnel have been protected
Work on Walls or Ceilings□ Construction and coverings are noncombustible □ All combustibles have been moved away from the opposite side of the wall
Work on Enclosed Equipment□ Equipment cleaned of all combustibles and flammables (Tanks, Containers, Ducts, Dust □ Containers purged of flammable vapors/gases and tested collectors, etc.)
Fire Watch□ To be provided during work □ To be provided for 30 minutes after the work has been completed □ Trained in the use of emergency equipment and the alarm systems |
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Fire Protection Check all that apply: □ Fire Extinguisher □ Fire Blankets □ Welding Blankets □ Water Hose□ Other (state): |
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Special Instructions (If extra space is needed, attach an additional sheet): |
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The work site has been inspected, lockout/tagouts verified, and the necessary precautions taken. To the best of my knowledge it is safe to proceed with the work described above. Work Supervisor’s Signature: Date Signed: This Permit Expires: |
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FINAL CHECK-UP (Hot Work Only) Work and surrounding areas (including floors above and below and on opposite sides of walls) were inspected 30 minutes after the work was completed. All areas were found to be fire-safe. Signed (Shop Supervisor, Work Supervisor, or Fire Watch): Date Signed: |
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