Building:_________________________________ Room #:__________________
Date:_________________________________Time:_________________________
PERSON REQUESTING PERMIT:______________________________________
| SAFETY | HEALTH | FIRE |
| Hazards: | Hazards: | Hazards: |
| Precautions | Y | N | n/a | Precautions | Y | N | n/a | Precautions | Y | N | n/a |
| Provide Guards | Possible Oygen Deficiency | Fire Extinguishers | |||||||||
| Personal Protective Equip. | Special Ventilation | Open Flame Permit | |||||||||
| Special Safety Training | Toxic Materials | Explosion Protection | |||||||||
| Lockouts Required | Special Rescue Procedures | Test Atmosphere | |||||||||
| Unattended Operation | Lockouts Required | Emergency Egress | |||||||||
| Work Alone | Exceed PELs | Pyrophorics | |||||||||
| Sole Occupancy | Unattended Operation | ||||||||||
Special considerations:
Additional Comments:
Name:
Date: