Electrical Code Equivalency Request Form

(See ES&H Manual Chapter 6200 Appendix T6 Electrical Code Equivalency Procedure for Instructions)

 

 

/////////////////////////////////////To be completed by the Electrical Authority Having Jurisdiction////////////////////////////////////

DETERMINATION:

 Approved      Denied     CATS No.

 

////////////////////////////////////To be completed by the Electrical Authority Having Jurisdiction/////////////////////////////////////

Signatures

Print

 

Signature

 

Date

Electrical Authority Having Jurisdiction

 

 

 

 

 

Electrical Safety Committee Chair

 

 

 

 

 

 

1.0          INITIATE REQUEST (To be completed by Requestor)

1.1            Identify Equipment, Installation, or Process

 

 

1.2            Location of the Work

 

 

1.3            Description of the Work

 

 

1.4            State the Specific Question or Problem. 

(List the specific code and section(s) that requires equivalency.) 

 

 

1.5            Describe the Proposed Mitigation– to satisfy the electrical safety equivalency.

 

 

1.6            Signatures

Print

 

Signature

 

Date

Requestor

 

 

 

 

 

Supervisor

 

 

 

 

 

 

2.0          DETERMINATION (To be completed by Electrical Authority Having Jurisdiction)

2.1            Scope Statement (i.e. only for the specific equipment identified in the request; for broader application to similar equipment; or for general application at Jefferson Lab.)

 

 

2.2            Specific Code and Section(s) Used - to justify the Determination.

 

 

2.3            Explain Determination:  

·        If the request is approved, include an explanation of the electrical safety aspects. 

·       If the request is denied provide reasoning and, if applicable, alternative(s).

 

 

 

Distribution:

IF

Code Equivalency is:

THEN

Approved

Associate Director-ESH&Q; Associate Director/Division Manager (of group requesting the equivalency); Thomas Jefferson Site Office Representative; Supervisor; Requestor; Electrical Authority Having Jurisdiction; Electrical Safety Committee Chair

Denied

Requestor; Electrical Authority Having Jurisdiction; Electrical Safety Committee Chair

 

Form Revision Summary

Revision 0 – 10/31/13 - New content to reflect current laboratory operations.

ISSUING AUTHORITY

TECHNICAL POINT-OF-CONTACT

APPROVAL DATE

REVIEW REQUIRED DATE

REV.

ESH&Q Division

Todd Kujawa

10/31/13

10/31/16

0

This document is controlled as an on line file.  It may be printed but the print copy is not a controlled document.  It is the user’s responsibility to ensure that the document is the same revision as the current on line file.  This copy was printed on 11/1/2013.