Hot Work Permit Form Hot Work Permit University of Connecticut: Fire Department hot work permit request form Procedure(Required) By checking this box and continuing, you have agreed to follow the UConn FD and EH&S Hot Work requirements, which can be referenced below. EHS Requirements UConn Hot Work Fire Safety Checklist Hot Work InformationToday's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920When is the Hot Work Permit requested for(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time(Required) Hours : Minutes AM PM AM/PM Permit Requester(Required) First Last Individual performing the Hot Work(Required) First Last Business Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Enter Email Confirm Email Contractor/Vendor or UConn Department(Required) Campus of Hot Work Storrs UConn Health Center Is the location of the hot work associated with a building?(Required) Yes No Building name the hot work is being conducted at(Required) Floor of Building(Required) Room or location within Building(Required) Building construction type(Required) Combustible Non-combustible Mix Area where hot work will be conducted(Required) Please describe the area and its location (e.g., utility vault, etc.).Anticipated duration of Hot Work(Required) *Not to exceed two weeksType of Hot Work(Required) Welding Grinding Cutting Brazing Torch-applied roofing Other Other type of Hot Work(Required) Please indicate/describeHot Work Job SiteThe following are Hot Work site requirementsAre the combustible structure(s) shielded (using Fire Marshal approved blankets and/or curtains)?(Required) Yes No N/A i.e. timber framing, insulation, lining, battenAre the combustible materials shielded (using Fire Marshal approved blankets and/or curtains) or removed (35 feet away)?(Required) Yes No N/A Have all the fixed potential fuel gases, flammable liquids, and ignitable liquids been either isolated or removed?(Required) Yes No N/A Have all the transient waste, trash, packing materials, dust/lint or oily deposits etc. been removed?(Required) Yes No N/A Have all the transient potential fuel gases, flammable liquids, ignitable liquids either been isolated or removed (35 feet away) ?(Required) Yes No N/A Have all piping or cylinders that hot work will be conducted on been purged?(Required) Yes No N/A Have all duct work and conveyors that may carry sparks to another location been protected, shut down and locked out?(Required) Yes No N/A Is the hot work associated with a roofing operation?(Required) Yes No N/A If yes, have any additional fire protection precautions been made?(Required)Please explainIs this hot work associated with a closed and/or pressurized container, equipment, or piping?(Required) Yes No N/A If yes, has it been purged and/or depressurized?(Required) Yes No Is the hot work equipment being used in good working condition?(Required) Yes No N/A i.e. extinguisher properly pressurized and in dateHave all wall, floor, and ceiling openings to the adjacent spaces been covered or protected?(Required) Yes No N/A Hot Work Job SiteThe following are Hot Work site requirements (Fire Watch requirements)Personnel conducting the fire watch are trained in the use safety equipment and sounding the fire alarm?(Required) Yes No N/A Personnel conducting the fire watch have good situational awareness of the job site, adjacent areas, and locations of where sparks, smoke, or slag could travel?(Required) Yes No N/A Personnel conducting the fire watch have been instructed to constantly monitor the hot work area during the use of the hot work equipment ?(Required) Yes No N/A Personnel conducting the fire watch have been instructed to constantly monitor the hot work area for a minimum of 30 minutes after the use of hot work equipment?(Required) Yes No N/A If you have any additional information that will assist with your request please add it belowHot Work Permit Process Explanation Once the hot work permit is submitted the Shift Commander will contact the requester via cell phone number provided in this form. The Shift Commander will schedule a site inspection to confirm the information provided and advise if anything additional is needed to issue a hot work permit. Once the inspection has been completed an email will be sent to the email provided in this form confirming a hot work permit has been issued. Please keep either an electronic or paper confirmation of the email. If for any reason you need to contact the Shift Commander, they can be contacted at uconnfirecapt@uconn.edu or 860.486.3938 Consent(Required) By checking this box I agree to the following:I verify the above location has been examined, the precautions outlined on the above checklist have been taken to prevent fire, and permission is authorized for this work.CommentsThis field is for validation purposes and should be left unchanged.