University Of New Haven - Fire Impairment / Hot Work Request

This form is to be used for all scheduled shutdown requests. Emergency Shutdowns are to be done
immediately at the request of the Facilities Manager or Safety Officer. This form will be filled out within
a 48-hour period after each Emergency Shutdown.

Permit #
Today's Date Today's Date / MM / DD YYYY
Requester Requester First Last
Phone Phone - ### - ### ####
Requester's Email
Campus Building
Location/Room
Work Being Performed
Work Performed By (Name) Work Performed By (Name) First Last
Work Performed By (Email)
Work Performed By (Phone) Work Performed By (Phone) - ### - ### ####
Add Another Contractor
Additional Contractor Name Additional Contractor Name First Last
Additional Contractor Email
Work Performed By (Phone) Work Performed By (Phone) - ### - ### ####
Add Another Contractor
Additional Contractor Name Additional Contractor Name First Last
Additional Contractor Email
Work Performed By (Phone) Work Performed By (Phone) - ### - ### ####
Add Another Contractor
Additional Contractor Name Additional Contractor Name First Last
Additional Contractor Email
Work Performed By (Phone) Work Performed By (Phone) - ### - ### ####
Add Another Contractor
Additional Contractor Name Additional Contractor Name First Last
Additional Contractor Email
Work Performed By (Phone) Work Performed By (Phone) - ### - ### ####
Date Work Begins Date Work Begins / MM / DD YYYY
Start Time Start Time : HH MM AM/PM
Date Work Ends Date Work Ends / MM / DD YYYY
End Time End Time : HH MM AM/PM
Does this Request Require Hot Work?

Does this Request Require Hot Work? Yes - This Request Requires Hot Work No - This Request Does Not Require Hot Work
Is this a level 1 request? (Request to take entire building(s) offline)

Is this a level 1 request? (Request to take entire building(s) offline) Yes No
Hot Work Request
Tools Required (Must include ALL flame/spark producing tools being used)

Tools Required (Must include ALL flame/spark producing tools being used) Torch Welding Machine Grinder Drill or Saw Electrically Driven Equipment/Machine Engine (Internal Combustion) Hammer (Chipping/Jack) Other Other

Equipment and Work Area Preparation
Equipment and Work Area Preparation
Empty Vessel/Tank	Empty Vessel/Tank
Vent	Vent
Purge	Purge
Blind or Disconnect	Blind or Disconnect
Wash	Wash
Steam	Steam
Cool Ventilate	Cool Ventilate
Energy Lockout	Energy Lockout
Equipment Tagging	Equipment Tagging
Combustible Material Removed or Shielded	Combustible Material Removed or Shielded
Decomposition Reaction Potential Minimized	Decomposition Reaction Potential Minimized

Received Training On:
Received Training On:
Safe Work Practices	Safe Work Practices
Location of Emergency Equipment	Location of Emergency Equipment
Hot Work Permit Procedure	Hot Work Permit Procedure
Use of Fire Safety Equipment	Use of Fire Safety Equipment

Equipment
Equipment
Water	Water
Air Blower	Air Blower
Face Shield	Face Shield
Barricades	Barricades

Additional Equipment/Precautions

Atmosphere Evaluation
Atmosphere Evaluation
Oxygen Content %	Oxygen Content %
Explosive Gasses	Explosive Gasses
Toxic Gasses	Toxic Gasses
Other	Other

Atmosphere Evaluation Results - Explosive Gasses
Atmosphere Evaluation Results - Explosive Gasses
Atmosphere Evaluation Results - Toxic Gasses (Please Specify)
Atmosphere Evaluation Results - Other (Please Specify)

Additional Actions
Additional Actions
Sprinklers Present and Functional	Sprinklers Present and Functional
Smoke Detectors and Alarms Disabled Through Campus Police	Smoke Detectors and Alarms Disabled Through Campus Police
Provisions Made for 2 Hour Reinspection	Provisions Made for 2 Hour Reinspection

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