Work Authority Permit Request Form

WORK AUTHORITY PERMIT REQUEST FORM

This Work Authority Permit Request Form authorizes review and consideration of requested work at a specified location and sets forth terms and conditions under which work may be authorized. Issuance of a permit is subject to approval by the Authorized Issuing Authority and compliance with the conditions contained herein.

WHEREAS

WHEREAS, Requesting Party seeks authorization to perform the work described in this form at the Work Location; and

WHEREAS, the Owner/Facility reserves the right to grant, condition, modify, suspend or revoke work authority in order to protect health, safety, the environment and property; and

WHEREAS, issuance of a permit requires that Requesting Party comply with all insurance, safety, inspection and certification requirements set forth by the Owner/Facility and applicable law.

REQUESTING PARTY INFORMATION

WORK LOCATION & SCHEDULE

Proposed Start Date:

Estimated Completion Date:

Work Hours: Day Night Continuous

SCOPE OF WORK

REQUIRED PERMITS, ATTACHMENTS & SAFETY CONTROLS

Required Permit Types (check all that apply): Hot Work Confined Space Electrical Excavation Crane/Lift

Lockout/Tagout Required: Yes No

PAYMENT TERMS

If applicable, payment for approved work will be governed as follows. Requesting Party affirms any invoice will reference the issued permit number and work dates.

Late Payment Fee:

TERM AND TERMINATION

This permit request, if approved, authorizes work only for the period expressly stated by the Authorized Issuing Authority. Approval may be conditioned on a start date and expiration date and may be revoked at any time for noncompliance.

Proposed Authorization Start Date:

Proposed Authorization End Date:

Notice Period for Termination by Owner/Facility (days):

CONFIDENTIALITY

Requesting Party shall maintain as confidential all proprietary information, trade secrets and nonpublic data obtained in connection with the performance of authorized work. Confidential information shall not be disclosed except as required by law or with prior written consent of the Owner/Facility. This obligation shall survive expiration or termination of any permit.

GOVERNING LAW

This form, any permit issued pursuant to it, and the rights and obligations of the parties shall be governed by and construed in accordance with the laws of the state of without regard to choice of law rules.

ENTIRE AGREEMENT

This form, together with any issued permit, attachments and written conditions imposed by the Authorized Issuing Authority, constitutes the entire agreement with respect to the subject matter hereof and supersedes all prior representations and understandings, whether written or oral.

CERTIFICATION AND ACKNOWLEDGMENT

By submitting this form, Requesting Party certifies that the information provided is true and complete to the best of its knowledge; that it will carry out the work in accordance with all applicable laws, regulations and Owner/Facility requirements; and that it will maintain required insurance and provide proof upon request.

I certify compliance with the certification statement above.

Additional remarks or conditions requested by Requesting Party:

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