Please enable JavaScript in your browser to complete this form.Live Work Policy a) Switch boards, panels, motor control centers and disconnects labeled as (No Live Work) in all cases the equipment is to be deenergized and locked out prior to opening or removing any covers or work initiated on equipment. A hot work permit shall still be required, and appropriate safety protocols and proper PPE will be required until all live parts to which you might be exposed are tested and determined to be in an electrically safe working condition. b) No live work permits will be approved in any circumstance for work on switch boards, panels, motor control centers and disconnects that will require PPE exceeding category 2 PPE' in all cases the equipment is to be deenergized and locked out prior to opening or removing any covers or work initiated on equipment. A hot work permit shall still be required, and appropriate safety protocols and proper PPE will be required until all live parts to which you might be exposed are tested and determined to be in an electrically safe working condition. c) WORKING NEAR LIVE CIRCUITS. Knock-out of panels and pulling wire into panels will be allowed, provided the work is performed on DE-ENERGIZED PARTS only, accept where work does not comply with part (a,b) of the Hot Work Policy above. A hot work permit shall still be required, and no metal fish tapes, or uninsulated tools shall be used. Appropriate safety protocols and proper PPE will be required until all work has been completed and covers have been put in place, All work near live circuits must be approved by a qualified supervisor. I acknowledge I've read and undersand Van Brocklin Electric's Live Work PolicyI acknowledge I undersand the Arc Flash Boundry ImageRequesting Person *Job Number or Name *Job Site *Equipment and/or circuits to be worked on energized *Date of work to be performed *Description of work to be performed *Physical location of equipment and/or circuits at site *Statement of why equipment cannot be de-energized *Is it possible to reschedule work at a later date when equipment may be de-energized? *YesNoHazards (risk to personnel, property, and production) *Flash Protection Boundary *AFC Less than 1.5 kA = 3 ftAFC Greater than or equal to 1.5 kA and less than 3 kA = 4 ftAFC Greater than or equal to 3 kA and less than 7 kA = 6 ftAFC Greater than or equal to 7 kA and less than 10 kA = 8 ftPPE Category Based Off Table 3 Below *Category 1Category 2Category 3Category 4Limited Approach Boundary NFPA 70E Table 130.4(E)(a) *3' 6"5'6'8'10'11' 8"13'15' 4"19'23'Restricted Approach Boundary NFPA 70E Table 130.4(E)(a) *1'2' 1"2' 2"2' 7"2' 10"3' 4"3' 9"4' 4"4' 10"6' 8"11' 2"14'16' 8"22' 7"Employees who will be performing the energized work *Have employees been properly trained? *YesNoHave affected employees been notified of procedures and hazards? *YesNoDate / Time of Notification *DateTimeCompetent person assigned to notification *FirstLastEnergized Work Category: *50-250 Volts250-600 Volts>600 VotlsList personal protective equipment needed *Arc Flash PPE Categories *Arc Flash PPE Category 1Arc Flash PPE Category 2Arc Flash PPE Category 3Arc Flash PPE Category 4Has a writen plan/Task Safety Analysis been completed for energized work? *YesNoUpload a copy of your written plan/Task Safety Analysis (TSA) * Click or drag a file to this area to upload. Authorized Customer representative approvalFirstLastCustomer representative understands all risks: injury, damage, and loss of production (Required for all energized work)Date and Time of authorized customer representative approvalDateTimeCompenent Person *FirstLastDate and Time *DateTimeSupervisor *FirstLastDate and Time *DateTimeSubmit
