LOTO Permit

This permit must be completed before work begins and posted/available at the site of energy isolation for the duration of the work.

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Nothing in this communication alters or modifies any Subcontractor contractual responsibility for all construction means, methods, techniques, sequences, procedures or coordination of all portions of their Subcontract Work at all times during the performance of the Subcontract Work in accordance with the applicable Subcontract and Contract Documents; nor is this communication a modification or waiver of any Subcontractor's contractually assumed responsibilities with respect to the same.

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Job Permit Request Date & Time Company Performing Work Company Contact Name Contact Phone Contact Email Description Site Pod/Cell/Space Equipment Isolated Arc Flash Incident Energy Arc Flash Boundary PPE Category Required for Live-Dead-Live Description of Work Being Performed Energy Isolation Equipment (LOTO, GND Clusters, etc.) Tamper Seal Numbers to be Removed/Replaced Electrical Energy Present? Hydraulic Energy Present? Pneumatic Energy Present? Mechanical Energy Present? Stored or Other Energy Present? One-Line Drawing or System Diagram Attached? Precautions, Restrictions, or Comments on Energy Sources First Source (Equipment ID / FB Designation) Second Source (Equipment ID / FB Designation) Other Source - UPS (Equipment ID / FB Designation) Have Affected People Been Informed of Hazards? How Were They Notified? Who Was Notified? Additional Safe Work Permits Needed Other Safe Work Permit (specify) Authorized Employee(s) Performing LOTO Affected Employee(s) Supporting Documents Optional: attach up to 4 files (photos or PDFs - a one-line drawing, additional permits, etc.). Up to 10 MB each.