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ROOF ACCESS PERMIT

A permit must be completed for each access procedure.
Roof access doors are unlocked by Facilities personnel only (DO NOT prop doors!).
POST IN AREA DURING PROCEDURE – RETURN TO DPR/F WHEN THE PROCEDURE IS COMPLETE.
MAKE SURE YOU HAVE MEANS OF COMMUNICATION VIA CELL PHONE AND/OR WALKIE-TALKIE.
WORK TAKING PLACE ON ROOF MUST BE A CREW OF AT LEAST 2 PEOPLE.
WHILE ON THE ROOF, YOU MUST STAY >6 FT FROM THE EDGE UNLESS APPROPRIATE FALL PROTECTION IS IN USE.

APPLICANT INFORMATION
Applicants Name(s):
Partner/ “Buddies” Name
Company:
Communication Device to be used during procedure:
Phone Number:
Facebook/ DPR/F Escort Required?:
Yes No
PROCEDURE INFORMATION
Location (include building number):
Purpose (be specific):
Start Date:
Finish Date:
Start Time:
Finish Time:
Does the procedure involve hot work?: (if yes, complete a hot work permit)
Yes
No
Fall Protection Training/Verification Completed?:(If no, please contact safety)
Yes
No
PERSONAL PROTECTIVE EQUIPMENT REQUIREMENTS
Fall Protection
Full Body Harness
Hard Hat
Safety Glasses
Goggles
Safety Footwear
Additional Lighting
Other: (i.e. Ladders, Scaffolds)
APPROVALS
PRINT/SIGNATURE
DATE
Requester
Partner/ “Buddies”:
Requester Supervisor:
DPR/F Representative:
A Copy Of This Permit Must Be Posted At Work Area While Work Is Taking Place. The Original Is To Be Left With DPR/F Safety.