1/2015 Revised

SECTION I JOB NAME: WORK ORDER #:

Extended Duration: ____________ One Time Use Only: ___________ Date Start: ______________ Expiration Date: ______________

(max. 6 months)

Building: Room/Area: Job Supervisor:

Description of work to be done:

Description of Circuit/Equipment:

Justification for why equipment cannot be de-energized: (check one)

Note: preference is always to work de-energized.

Exemption 1: De-energizing introduces additional or increased hazards. Examples include interruption of life support equipment, deactivation of emergency alarm systems, shutdown of hazardous location ventilation equipment, or removal of illumination for an area.

Explain: ______________________________________________________________________________

Exemption 2: De-energizing is infeasible due to equipment design or operational limitations. Example include testing of electrical circuits that can only be performed with the circuit energized, and work on circuits that form an integral part of a continuous industrial process in a

chemical plant that would otherwise need to be completely shutdown in order to permit work on one circuit or piece of equipment.

Explain: ____________________________________________________________________________________

SECTION IIAPPROVALS TO PERFORM THE WORK WHILE ELECTRICALLY ENERGIZED

(Add signature and date)

______________________________________ Person Requesting the Work _________ Date

______________________________________ Qualified Worker _________ Date

_______________________________________ Authorized Owner/Representative _________ Date

(Signature of Qualified Worker verifies the worker is trained and informed of all hazards relevant to this work task.)

Two persons required for energized work over 240 volts

SECTION IIIRESULTS OF THE SHOCK RICK ASSESSMENT Protective Boundaries and Glove Class

Shock Hazard Maximum Voltage _____________________________ Glove Voltage Rating ________________________

(Check gloves before use and check certification date inspection date within 6 months)

Indicate which boundaries apply by checking the following boxes: (The dimension associated with each of the boundaries depends on the

maximum voltage to which a worker might be exposed: All dimensions are distance from energized electrical conductor or circuit part to

employee)

Limited Approach Boundary

Closest approach distance for an UNQUALIFIED person.

Nominal System

Voltage Range, Exposed Movable Exposed Fixed

Phase to Phase Conductor Circuit Part

Check one:

50 300 Volts 10 FT. 3 FT. 6 IN. 301 750 Volts 10 FT. 3 FT. 6 IN. ____________ ____ __________ Label ______________________________________

Restricted Approach Boundary

Closest approach distance for a QUALIFIED worker unless voltage rated gloves and tools are used.

Includes Inadvertent Movement Adder

50-150 Volts Avoid Contact 151-750 Volts 1 FT. 0 IN. _____________________ Label ____________________

NOTE: ALL WORK AREAS WILL BE BARRICADED TO PREVENT UNQUALIFIED PERSONS ENTERING/CROSSING THE

LIMITED APPROACH BOUNDARIES

7625 Boone Ave. No.

Brooklyn Park, MN 55428

763-544-4131

Energized Electrical Work Procedure and Permit

1/2015 Revised

SECTION IV - RESULTS OF THE FLASH RISK ASSESSMENT (NFPA 70E 2009 130.3) Hazard Rating and Protective Boundaries

Label ______________________________________________________ Arc Flash Boundary: Using table 130.7(C)(15)(A)(b) or 130.7 (C)(15)(B)

Any person working within the Flash Boundary will be required to use the appropriate level of Arc Flash PPE.

To determine the correct level of PPE, refer to:

Label ______________________________________________________ Personal Protective Equipment (PPE) Selector

Or

NFPA70E Table 130.7(C)(15)(A)(b) or 130.7(C)(15)(B)

Or

Level of PPE

0 1 4 Cal 2 8 Cal 3 25 Cal

4 40 Cal SECTION V JOB BRIEFING (Description of Safe Work Practices to be employed)

Document job debriefing by reviewing and checking all categories below. Document any discussion relating to any job specific hazards here:

Identify

The hazards The voltage levels involved Skills required Any foreign (secondary source) Any unusual work conditions Number of people needed to do the job The shock protection boundaries The available incident energy

Ask

Are backfeeds of the circuits to be worked on possible? Is a standby person required?

Check

Job plans Single-line diagrams and vendor prints Status board Information on plant and vendor resources is up to date Safety procedures Vendor information Individuals are familiar with the facility

Know

What the job is Who else needs to know Communicate! Who is in charge

Think

About the unexpected eventWhat if? Lock Tag Test -Try Test for voltage FIRST Use the right tools and equipment, including PPE Install and remove grounds Install barriers and barricades What Else..?

Prepare for an Emergency

Is the standby person CPR trained? Is the required emergency equipment available? Where is it? Where is the nearest telephone? Where is the fire alarm? Is confined rescue available? What is the exact work location? How is the equipment shut off in an emergency? Are the emergency telephone numbers known? Where is the fire extinguisher? Are radio communications available?

Briefed Qualified Worker _________________________________________Date ______________________________________

Briefed Qualified Worker _________________________________________Date ______________________________________

RETURN COMPLETED AND APPROVED WORK PERMITS TO THE EGAN PROJECT MANAGER

2015 NFPA70E Standard is available on Chromebooks/Reference materials NFPA70E Handbook for Electrical Safety in the Workplace