Permit Request • CampusOptics

Submit this form to CapU Safety in advance of the first planned workday

This form is initiated by the employee or contractor requesting the service shutdown
This request will be reviewed and verified by CapU Safety prior to approval of the shutdown
Upon approval, CapU Safety will authorize the request and the CapU Liaison will inform the requesting party
All contractors must attend a site orientation prior to starting work and annually thereafter
Contractors will sign in and out with security each day that they are on campus
Attach copies of hazard/risk assessments, safe work procedures, training certificates and other safety documents below

PLEASE CONTACT YOUR CAPU LIAISON FOR ADDITIONAL INFORMATION

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Project Name* Required

CapU Liason* Required

Office/Cell* Required

Company Name* Required

Site Supervisor* Required

Cell* Required

Building/area impacted* Required

Scope of Work - system components and area being affected* Required

Please select the following that apply:* Required

Add files to upload as supporting documentation along with your permit request.

Files