* Name of Responsible Person:
* Email Address:
* Telephone Number:
* Performing Shop or Company:
General Maintenance
Other CSM
Contractor/Supervisor (enter Company Name or Supervisor Below)
Company Name or CSM Supervisor's Name:


* Work Start Date:
* Work Start Time:
* Work End Date:
* Work End Time:
* Building:
* Room, area, or equipment:
* Describe the work to be performed:


Hot work equipment will be inspected and determined to be in good repair prior to the start of work.
This work cannot reasonably be done in a shop or other area designated for this purpose and equipped to minimize hazards.
No sprinklers will be taken out of service while this work is being done.
The potential for smoke, heat, airborne dust, etc. to trigger a fire alarm has been evaluated and appropriate measures will be taken to prevent false alarms (including both local horns and strobes and the automatic Fire Dept. notification). Advance arrangements may be necessary for Electricians to deactivate and restore systems or components. Ensure that systems are restored as soon as possible after the completion of work so that fire watches can be minimized.
There are no combustible fibers, dusts, vapors, gases or liquids in the area. There are no tanks or equipment that previously contained flammable liquids in this area or they will be purged and the absence of explosive gases or vapors verified with a combustible gas detection instrument prior to the work. If there is a possibility of a leak developing in nearby piping, equipment, or tanks containing flammable liquids or gases, the area will be continuously monitored for hazardous conditions with appropriate instruments. Call EHS at x3316 if assistance is needed to test area.
All combustibles will be relocated 35 feet from the operation and the remainder protected with metal guards or flame-proofed curtains or covers (not ordinary tarpaulins).
Fire alarms will not be taken out of service or a suitable fire watch will be arranged. When possible, the EHS Dept. will be notified in advance if it is necessary to disable the alarm system for an entire building.
Surrounding floors will be swept clean and, if combustible, wet down.
Ample portable fire extinguishers and trained personnel to use them will be available at the job site. At a minimum, a 5 lb ABC rated extinguisher must be present in addition to the normal compliment of building extinguishers.
All floor and wall openings, including cracks, within 35 feet of the operations will be tightly covered.
The need for a fire watch during work, work breaks, and for 30 minutes after completion has been evaluated and an appropriate number of responsible personnel will be assigned to this duty.
There will be no harmful radiation generated by this work, or fire resistant screens will be positioned to protect bystanders.
Workers will not be exposed to toxic fumes and the work will not create an indoor air quality issue or else adequate ventilation will be provided to prevent these problems.
Prior to starting work, workers will determine the location of the nearest: alarm pull station, building fire extinguisher and telephone (accessible) and verify a clear escape route from the work area.
The person performing the hot work will verify the conditions specified in this permit prior to starting work each day that the permit is in effect. In addition they will document that verification or re-verification for each day after the start date by adding their initials, with the date, to the permit kept at the work site (directly below the signature line). Note: If the work needs to be continued beyond the completion date specified on the permit, then a new permit application should be submitted. (It is not acceptable to just keep initialing an expired permit.)
* The name of the Person Responsible for Performing Hot Work -- I personally surveyed the work site and attest that the above precautions are sufficient to prevent fire and unintended fire alarms, as well as to assure the health and safety of workers, bystanders, and building occupants. Entering name constitutes your REQUIRED SIGNATURE:

Print this form and post it at the worksite. Scroll down and press "Submit" to notify the Safety Officer and Facilities Management. If you have any questions, call the Safety Officer at 303-273-3391.

* required