DATE
THIS FORM IS SUBMITTED .
(ALLOW
FOURTEEN (14) DAYS PRIOR TO WORK ACTIVITY.)
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CONTRACTOR: |
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CONTACT
PERSON: |
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PHONE
NUMBER: |
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DATE
OF ACTIVITY: |
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START: |
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FINISH: |
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TIME
OF ACTIVITY: |
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START: |
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FINISH: |
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PROVIDE DESCRIPTION
OF:
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THIS WORK IS PER
DRAWING SHEET NO. |
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SPEC. NO. |
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WORK ACTIVITY:
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PLEASE PROVIDE AS
MUCH DETAIL AS POSSIBLE: |
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TYPE OF UTILITIES TO
BE SHUT DOWN: _________________________________________
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NOISE IMPACT (check
one) : LOW _______ MEDIUM _______ HIGH ________
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ANY OTHER IMPACT-
IS SIGNAGE REQUIRED, BARRICADES, SECURITY, RELOCATIONS, ETC. ?
______________________________________________________ |
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PROVIDE ANY OTHER DETAILS
AND IF SKETCH IS REQUIRED ATTACH TO THIS FORM
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SUBMITTED BY: |
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APPROVED BY DPW PROJ. MGR.: |
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DATE: ____________ |
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APPROVED BY FAC. PROJ. MGR.: |
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DATE: ____________ |