CONTRACT NO:

PERMIT NO:
AREA CLEARANCE
SITE:

ALL WORK UNDER THIS PERMIT REQUIRES A VALID CLEARANCE CERTIFICATE

REQUESTED BY DATE
CONTRACTOR RAMSU ENTERPRISE AREA/LOCATION
Description of Work:

Equipment to be Used:

Estimated Start Date: Estimated Finish Date:

CHECK SCHEDULE
Record of Buried Services REMARKS

Date: __________________________

Signature: ______________________
Mechanical Isolation Required:  Yes  No

Electrical REMARKS

Date: __________________________

Signature: ______________________
Electrical Isolation Required:  Yes  No

Safety REMARKS - ADDITIONAL PRECAUTIONS

Date: __________________________

Signature: ______________________

Overhead Services REMARKS

Date: __________________________

Signature: ______________________
Mechanical Isolation Required:  Yes  No
Electrical Isolation Required:  Yes  No