Electrical Work Permit Request Form
Requester Name
Department
Project/Work Description
Work Location
Date of Work
Type of Electrical Work
Installation
Maintenance
Repair
Other
Equipment/Systems Involved
Potential Hazards Identified
Control Measures/Safety Precautions
Power Isolation Required?
Yes
No
Permit Requester Signature
Date Requested
EIC/Supervisor Approval
Date Approved