HOT WORK PERMIT FORM


PLEASE TELL US WHO WILL DO THE WORK:

* Name of Responsible Person:
* Email Address:
* Telephone Number:
* Performing Shop or Company:
Structural Trades
HVAC
Plumbing
Electric Shop
Other Mines Department (enter supervisor's name below)
Contractor (enter company name, supervisor's name, and Mines project manager's name below)
Supervisor or contractor information:

TELL US ABOUT THE WORK ITSELF:

* Work Start Date:
* Work Start Time:
* Work End Date (not to exceed a week from start date):
* Work End Time:
* Building:
* Room, area, or equipment:
* Check type of work and describe the work to be performed:
Welding
Soldering
Grinding
Torch Work
Other
* Work to be performed:

VERIFY ALL OF THE FOLLOWING (CHECK ALL BOXES):

* Check all boxes:
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. If sprinklers have to be taken out of service while this work is being done, contact EHS for an alternate permit process at 303-273-3316.
The potential for smoke, heat, airborne dust, et cetera, to trigger a fire alarm has been evaluated and appropriate masures will be taken to prevent false alarms (including local horns and strobes and the automatic Fire Department notification). Advance arrangements may be necessary for Electricians or contractor NICET certified employee 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.
If fire-detection system is taken offline then describe the actions to be taken and/or name of Electric Shop employee or NICET certified employee performing work:
* Smoke detectors will be protected from dust and smoke intrusion in the immediate work area. Protection involves covering the detectors with plastic. PROTECTION MUST BE REMOVED AT THE END OF EACH WORK DAY.
Yes
No
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. If the equipment needs to be purged and the absence of explosive gases or vapors verified with a combustible gas-detection instrument OR if there is a possibility of a leak developing in nearby piping, equipment, or tanks containing flammable liquids or gases, then contact EHS for an alternate permit process at 303-273-3316.
All combustibles will be relocated or protected from sparks within 35 feet of the work area. Protection may include containment of sparks, flame-proofed curtains, non-combustible coverings, or wetting agents.
Surrounding floors will be swept clean of paper clippings, wood shavings, or textile fibers.
A 5 lb. ABC rated extinguisher must be present in addition to the normal compliment of building extinguishers. Trained personnel to use them must be available at the job site. For Mines personnel, contact EHS if a fire extinguisher is needed.
All floor and wall openings, including cracks, within 35 feet of the operations will be protected from spark intrusion.
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. Fire watch personnel must be in the immediate area of where the hot work was performed. (Based on the evaluation of the Hot Work Permit, EHS may require additional fire watch criteria.)
There will be no harmful radiation generated by this work, or protective measures will be taken. Protective measures may include fire-resistant screens or posting signage and restricting access to the work area.
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 keep initialing an expired permit.)

I 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. I understand that my company may be responsible for any fines incurred due to false alarms.
* Enter your name. This verifies that you have personally surveyed the work area and will stop work if the above conditions are not met.

PRINT THIS FORM PRIOR TO SUBMISSION and post it at the worksite. Scroll down, complete the "reCAPTCHA" test, and press "Submit" to notify EHS and Facilities Management. If you have any questions, call EHS at 303-273-3316.



* required