ATTACHMENT O

UNITED
GRATING REMOVAL/ OPEN HOLE PERMIT

Contractor:_______________________________ Date _________________ Starting Time:_______________

Location: __________________ ___________ Extended Dates: From: ____________ To :___________

Nature of Work:____________________________________________________________________________

_________________________________________________________________________________________

Grating may only be removed when the employees are equipped with fall protection, safeguarding / barricading for the hole
is provided and warning signage is in place.

Hole Watch Yes / No Barricades Yes / No Hole Cover Yes / No

Safety Harnesses with twin lanyards and shock absorbers Yes / No Anchorage Yes / No

Signage - "DANGER– OPEN HOLE PROTECTION - DO NOT REMOVE"

Hole must be covered or barricaded. Hole cover must be anchored / secured.

Open hole cover must be of substantial material. Minimum - 25 mm undamaged wood.

Approval to remove the grating:

Construction Superintendent: ___________________________________________ Date:_________________

(Print name and sign)

ATTACH AREA PLOT PLAN INDICATING THE EXCACT LOCATION WHERE THE GRATING HAS TO BE
REMOVED.

Joint Jobsite Visit after grating has been removed and cover / barricading is in place. By signing below the parties verify
that the area is safe and that all requirements have been met.

Field Supervisor ____________________________________ Date: ________________ Time: ________

Safety Supervisor: __________________________________ Date: ________________ Time: ________

RESTORING OF WORK AREA

Grating put in place, clips attached Yes No

If "no," is in the following condition: _____________________________________________________________

Hole filled in: _____ Yes _____ No

If "no," is in the following condition: _____________________________________________________________

Contractor Safety: _______________ Date ____________

Field Supervisor: _____________________________________ Date: ______________

/conversion/tmp/scratch/449983774.doc