Yes 
No| Company Name | |
| Project Site | |
| Working Dates To | Starting Time |
| Need Keys to Building? Yes No | Rooms |
| Contact Person (Company) | Emergency Phone |
| Project Coordinator (University) | Extension |
| Electric | Water | Gas | Heating | Ventilation | Air Conditioning |
| Fire Alarm | Telephone | Other | |||
| Paint | Floor Tile | Concrete Sealant |
| Mastic or Glues | Epoxy Coatings | Roofing Materials |
| Fiberglass | Explosive Fasteners | Other |
Will any welding or cutting be done? Yes No
If yes, permit will be issued for these tasks by the Director of Environmental & Occupational Health & Safety, Room 2046, Cushwa Hall, 941-3700. Permit must be obtained before work is begun.
Will the work involve the use of chemicals or materials which may release vapors or odors?
Yes 
No
The contractor must supply copies of MATERIAL SAFETY DATA SHEETS of all HAZARDOUS CHEMICALS used in the project to the DEPARTMENT OF ENVIRONMENTAL & OCCUPATIONAL HEALTH & SAFETY before starting the project. Be advised that all contractors arriving on campus to perform a job must contact the UNIVERSITY PROJECT COORDINATOR before initially starting a job, and must complete this form with all pertinent information requested. If any work involves asbestos material or the use of hazardous materials, the department of Environmental & Occupational Health & Safety must be notified. Likewise, if the contractor is assigned a task in the areas which contain hazardous materials, a representative from the department of Environmental & Occupational Health & Safety or a University designee will accompany the contractor to the site and will give direction pertinent to hazards which may be present. Hazardous materials shall be delivered, stored, and used in accordance with all Federal, State and local regulations. All leaks and spills shall be reported at once to the department of Environmental & Occupational Health & Safety. No disposal of hazardous materials shall be permitted unless approved by the Director of Environmental & Occupational Health & Safety.
The contractor agrees to adhere to all Occupational Safety and Health Administration's regulations as found in 29 CFR 1910 and 1926. The contractor also agrees to provide to the Director of Environmental & Occupational Health & Safety evidence of written lockout/tagout, confined space entry, hazard communication, and hearing conservation programs before beginning any work on the University campus. The University reserves the right to request from the contractor any other pertinent health and safety programs required by OSHA.
| As an agent of the above company, I agree to all of the above conditions. |
Contractor's Authorized Representative
| Approved | Disapproved |
Project Coordinator
| Approved | Disapproved |
Director, Facilities Maintenance
| Approved | Disapproved |
Director, Env & Occ Health & Safety
Room 2046, Cushwa Hall, Phone: (216) 941-3700 Revised 9-22-08