SUBCONTRACTOR/VENDOR LOCKOUT TAGOUT(LOTO) PERMIT APPLICATION

This is not an approved Permit
Required fields are marked with an*

*Subcontractor/Company Name:
Subcontactor Representative:
Subcontactor Representative Email:
*LBNL Point Of Contact:
*LBNL Point Of Contact Email:
Project Name:
*Construction/Non-construction:
Work Scheduled Date (mm/dd/yy):
*Requested Permit Expiration Date (mm/dd/yy):

Completing this permit application serves as your company's LOTO Plan for this activity (see also #17)

An approved LOTO Permit is required before work begins.

Subcontractor, Please Read:

1. Please fill out this permit application as completely as possible. Leave blank any items to which you do not know the answer. We will fill it in.

2. This permit is required to be filled out and submitted to your LBNL Point of Contact (i.e., Project Manager (PM), Construction Manager (CM), Service Requester, etc) for any project each time lockout/tagout (LOTO) is required. Do not submit it directly to the Electrical Safety Officer unless requested to do so. You are required to lockout and tagout all potentially hazardous energy sources from any equipment or system on which you are performing servicing, maintenance or modification. This includes working near exposed potentially energized parts. Any work that cannot be done under LOTO requires special permission. See PUB 3000, Chapters 8 and 18 for more information.

3. The following regulations apply to LOTO at LBNL. Where there is a conflict between regulations the more stringent regulation shall apply. Federal OSHA 29 CFR 1910.147, 1910.333 Subpart S (Electrical), CalOSHA Title 8 CCR, NFPA 70E Standard for Electrical Safety in the Workplace, and if applicable, Federal 29 CFR 1910.269 Subpart R and ANSI C2 NESC. Also, LBNL PUB 3000, Chapter 18.

LBNL REQUIRES THAT EACH EMPLOYEE WHO IS WORKING ON THE LOCKED OUT EQUIPMENT HAS A PERSONAL LOCK AND TAG ON THE ENERGY ISOLATING DEVICE.

THE LOCK YOUR COMPANY USES FOR THIS PURPOSE SHALL BE RED.

THERE SHALL BE ONLY ONE KEY PER LOCK. SPARE, MASTER, AND EMERGENCY KEYS ARE NOT ALLOWED ON SITE.

ALL ELECTRICAL CONDUCTORS SHALL BE REGARDED AS ENERGIZED UNTIL PROVEN SAFE.

LIVE WORK METHODS AND PPE SHALL BE USED WHILE VERIFYING THE ABSENCE OF ENERGY.

EXEMPTION FOR CORD AND PLUG CONNECTED EQUIPMENT. Complete this section only if all of the equipment to be worked on is cord-plug connected.
1. The equipment is electrically connected by a cord and plug.
2. Unplugging the equipment removes all forms of hazardous energy
3. The equipment will remain unplugged for the duration of the servicing and maintenance process. There will be no time that the equipment will be plugged in while any guards or covers are removed.
4. The plug will remain constantly under the exclusive control of the servicing technician for the duration of the servicing and maintenance process.
IF ALL BOXES ARE ANSWERED YES, STOP HERE, TYPE YOUR NAME IN THE BOX BELOW, AND SUBMIT THE FORM TO YOUR POINT OF CONTACT. DO NOT COMPLETE THE REST OF THE APPLICATION. Company Representative:

1. Name of Equipment:

2. Identification:

*3a. Facility:

3b. Building:

3c. Room:

4. Fed From:

5. Drawing Number:

6. Circuit type:
If Other describe:

7. Areas Affected by LOTO:

8. Description of Energy Isolating Device(s): *(circuit / panel number(s), valve number, etc)*

9. ELECTRICAL ENERGY HAZARDS
*(Check all that apply)*
120V	240V	480V	Less than 50 Volts
208V	277V	Capacitors	UPS/Standby/Emergency pwr	DC
Other *(Describe)*:

10. OTHER ENERGY SOURCES TO BE CONTROLLED
*(Check all that apply)*
Mechanical	Pneumatic	Chemical	Hydraulic
Water	Steam	Gas
Other *(Describe)*:

10b. Is an Equipment-Specific LOTO procedure required for LOTO?

Any equipment with multiple energy sources or other complexities shall require an equipment-specific LOTO procedure before LOTO will be allowed (see PUB 3000, CH 18). Please check with your LBNL contact to determine whether such a procedure already exists, or will need to be written.

Attach Equipment Specific Procedure:

*Note: if you need to attach more than one document please call Keith Gershon x4694

11. DESCRIBE THE WORK TO BE PERFORMED AFTER EQUIPMENT IS LOCKED OUT.
(i.e. reason for LOTO; please be as specific as possible)

12. HOLD POINTS
A. STOP WORK IF ANY UNEXPECTED ENERGY IS FOUND B. STOP WORK IF EQUIPMENT HAS BEEN MODIFIED SINCE THE AUTHORIZATION WAS ISSUED C. STOP WORK IF ANY UNANTICIPATED CIRCUITS OR EQUIPMENT ARE FOUND TO BE AFFECTED BY THE LOTO

D. ENTER ANY ADDITIONAL HOLD POINTS FOR THIS PROJECT:

NOTE: Work is not authorized beyond any hold point until the issue has been resolved! Discovery of new conditions will require this permit to be re-issued.

13. SPECIAL INSTRUCTIONS:

14. Check this box if verification does NOT require ELECTRICAL testing, and SKIP Sections 15 and 16.

Describe verification process for NON-ELECTRICAL energy sources in the box below.

Electrical LOTO verification is treated as energized work

15. APPROACH BOUNDARIES TO LIVE PARTS FOR SHOCK PROTECTION (from NFPA-70E)

SYSTEM VOLTAGE	LIMITED APPROACH DISTANCE	RESTRICTED APPROACH DISTANCE	PROHIBITED APPROACH DISTANCE
	*(Authorized and Qualified Only)*	*(Electrical Shock PPE Mandatory)*	*(Equivalent to Contacting Exposed Parts)*
50 to 300V	3'6"	avoid contact	avoid contact
301 to 750V	3'6"	1'0"	0'1"
751 to 15kV	5'0"	2'2"	0'7"
15.1 to 36kV	6'0"	2'7"	0'10"

16. FLASH HAZARD ANALYSIS - LEAVE BLANK IF NOT KNOWN
EXEPTION FOR LOW POWER EQUIPMENT Check this box and skip section 16 if the circuit is rated less than 240 volts, supplied by one transformer, AND the transformer is rated less than 125kVA. Flash hazard PPE / Flash Protection Boundary is not required.
Checked By:

Determine Flash Hazard by EITHER 16a, or 16b.

16a Hazard Risk Category and Flash Protection Boundary Labeled.

Location Of Label:

Enter information from Flash Hazard Label on the equipment or first upstream labeled panel.

Flash Protection Boundary *(Flash PPE Required)*:

Incident Energy *(Cal/cm2)* :

Hazard / Risk Category:

Checked By:

Is Arc Flash data from the Emerson /ERS study, on record?

Flash Protection Boundary (Flash PPE Required):

Incident Energy (Cal/cm2) :

Hazard / Risk Category:

Checked By:

16b. Hazard Risk Category and Flash Protection Boundary Calculated.

Assumptions used for calculation:

Clearing Time:

Transformer Rating:

Bolted Fault Current:

Engineering Calculation Results:

Flash Protection Boundry (Flash PPE Required):

Incident Energy (Cal/cm2):

Hazard / Risk Category

Calculated by :

16c. PERSONAL PROTECTIVE EQUIPMENT TO BE WORN DURING ELECTRICAL VERIFICATION ( See Table 130.7(C)(10) )
		Cal Rating
Natural Fiber Clothing	FR Long Sleeve Shirt
Eye Protection	FR Pants
Long Pants	FR Coverall
Long Sleeve Shirt	FR Jacket
V-rated gloves/leather protectors	FR Flash suit jacket
Hard hat	FR Flash Suit
Hearing Protection (canal-inserts)	Arc-rated face shield
V-rated tools	Flash suit hood
Other (Describe):	Balaclava (sock hood)

*16d. BARRIERS: How will the Approach Boundries be protected?

If Other (Describe):

16e. WORKER SUPPORT REQUIRED:

Other (Describe):

17. LOTO PROCEDURE

Please attach a copy of the subcontractor's LOTO policies and procedures. This will help us to evaluate the degree of assistance required by LBNL staff.

LOTO Step	Performed by?	Comments
A. Notification and preparation including review of all hazards and controls and full employee briefing
B. Equipment shut down using established control methods.
C. Operation of energy isolating devices.
D. Application of LOTO locks and tags to energy isolating devices by each worker
E. Bleed, block, Restrain stored or potential energy.
F. Verify Zero Energy State
G. Use of electrical PPE during verification
H. Witnessing verification performed by others
I. Treating all electrical parts as live until positively proven otherwise and locked out.
J. Notifying affected individuals when equipment is to be released from LOTO.
K. Ensuring that personnel are safely positioned before releasing equipment from LOTO.
L. Ensuring that equipment is safe to re-start before releasing from LOTO.

*Submitted by: To: