Energized Electrical Work Permit

Energized Electrical Work Permit
Date*

MonthDayYear
Date
State*
Project Name*
Project Number*
Electrical Subcontractor and/or Person Performing the Work?*
Requestor Name*

First NameLast Name
Requestor Email*
example@example.com
Under NFPA 70E, there are only two instances in which an employee can work on live parts. In these situations, a work permit must be completed and approved by an authorized person.
1. When de-energizing would interrupt essential life support, emergency alarms or ventilation systems.
2. When the organization can demonstrate that de-energizing the system would introduce additional or increased hazards or that it is infeasible due to equipment design or operational limitations.
Details

What are you planning to do?
Description of circuit/equipment/job location: *
Description of work to be done: *
Justification

Why is this work being performed without first de-energizing the system?
Justification of why the circuit/equipment cannot be de-energized or the work deferred until the next scheduled outage: *
Hazard Mitigation
1. Detailed job description procedure (JHA, JSA, JRA, etc.) to be used in performing the above detailed work:*

YesNo
2. Description of the safe work practices to be employed:*

YesNo
3. Results of the shock hazard analysis:*

YesNo
4. Determination of shock protection boundaries:*

YesNo
5. Results of the flash hazard analysis:*

YesNo
6. Determination of the flash protection boundary:*

YesNo
7. Necessary personal protective equipment to safely perform the assigned task:*

YesNo
8. Means employed to restrict the access of unqualified persons from the work area:*

YesNo
9. Evidence of completion of job briefing including discussion of any job-related hazards:*

YesNo
10. Do you agree the above described work can be done safely?*

YesNo
Approvals

All the following approvals are required prior to starting work!
Superintendent Approval*

YesNo
PM Approval*

YesNo
RVP Approval*

YesNo
VP HSE Approval*

YesNo
*STOP*

Based on the above answers you provided, you are not qualified to perform Energized Electrical Work for the Company!!!
Should be Empty:

Energized Electrical Work Permit

Details

Justification

Hazard Mitigation

Approvals