Permit Request • CampusOptics

Use this form to temporarily reclassify a permit-required confined space to a non-permit confined space, which is only

valid for the duration of work being performed and for no more than 8 hours.

The space cannot contain any actual or potential atmospheric hazards, and all hazards within the space must be

eliminated without entry into the space. If someone must enter the space to remove hazards, the space must be

treated as a permit-required confined space until hazards have been eliminated.

Control of atmospheric hazards through forced air ventilation does not constitute elimination of the hazards.

If hazards can be permanently eliminated from a confined space, and the space can be reclassified as non-permit required

on a long-term basis, please contact EHS at ehssafety@mail.wvu.edu or (304)293-3792 to complete a Confined Space Evaluation.

Valid for one eight (8) hour shift

MUST BE POSTED ON WORK SITE

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

Campus, Building, or Outdoor Area* Required

Additional Location Details

Section 1: General

Purpose of Entry* Required

Department* Required

Entrant(s)* Required

Attendant(s)* Required

Section 2: Atmosphere Requirements

Flammable gas, vapor, or mist in excess of 10% of its Lower Flammable Limit is detected?* Required

Airborne combustible dust meets or exceeds its Lower Flammable Limit?* Required

Oxygen concentration is below 19.5 % or above 23.5%?* Required

Is there any dangerous substance in the atmosphere that are passed the Permissible Exposure Limit (PEL) or dose? (Published in 29 CFR 1910 Subpart G or Z)* Required

Are there any atmospheric conditions that are immediately dangerous to life and health?* Required

Section 3: Hazardous Energy Requirements

1a. Does the space contain chemical hazards?* Required

1b. If Yes, describe how the hazard was eliminated without entry into the space

2a. Does the space contain electrical hazards?* Required

2b. If Yes, describe how the hazard was eliminated without entry into the space

3a. Does the space contain engulfment hazards?* Required

3b. If Yes, describe how the hazard was eliminated without entry into the space

4a. Does the space contain mechanical hazards?* Required

4b. If Yes, describe how the hazard was eliminated without entry into the space

5a. Does the space contain entrapment hazards?* Required

5b. If Yes, describe how the hazard was eliminated without entry into the space

6a. Does the space contain extreme temperatures?* Required

6b. If Yes, describe how the hazard was eliminated without entry into the space

7a. Does the space contain any other serious hazards?* Required

7b. If Yes, describe how the hazard was eliminated without entry into the space

8a. Will the work being done inside or near the space introduce new hazards into the space? (ex. welding, chemicals, painting)* Required

8b. If Yes, describe how the hazard was eliminated without entry into the space

Certification and Authorization

By signing below, I certify that the space does not contain or have the potential to contain a hazardous atmosphere, all hazards within the space have been eliminated without entry, and no hazards will be introduced into or created within the space during the entry. I certify that all actions and conditions necessary for safe entry have been performed to temporarily reclassify the permit-required confined space to a non-permit confined space.* Required

Please Sign by typing your Full Name.* Required

Add Supporting Documents

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

Files