Permit Request • CampusOptics

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Name* Required

Additional Location Details

A. General Information

Work Order #* Required

Purpose of Entry* Required

Entry to be Completed by* Required

USF/SSC
Contractor

B: HAZARDS OF SPACE TO BE ENTERED

Mech/Electrical* Required

Moving Parts
Agitator
Electrical

Other* Required

C: PPE & EQUIPMENT REQUIRED FOR ENTRY

Other PPE List* Required

D: CRITICAL CONFINED SPACE ENTRY

Contracted CSE rescue team is required (Section H) and pre-entry review signatures are required (Section J)* Required

E. ADDITIONAL PERMITS

Additional Permits?* Required

LOTO
Hot Work Permit
Other

Hot Work Permit #

Other Description

F: ATMOSPHERIC MONITOR VERIFICATION OF CALIBRATION (pre-use)

Make/Model* Required

Equipment S/N#* Required

Verified By* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files