Permit Request • CampusOptics

University of Texas at Tyler ~ 3900 University Blvd. Tyler, TX 75799

It is requested that noted building system(s) be “shutdown” by the owner to allow for our tie-in of services for the project as enumerated below. The EH&S department requires 48 hours advance notice (as a minimum) and at least (1) week for research facilities; all shutdowns should occur during other than regular working hours. I hereby certify that the required work has been coordinated and schedule to achieve completion with the requested time period.

If a fire system shutdown is needed please complete a Fire System Shutdown Request:

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Emergency Phone Numbers:

Environmental Health and Safety: (903)-566-7011
UT Tyler Emergency Dispatch: (903)-566-7300
Physical Plant: (903)-566-7431

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Utility Shutdown

Project Name and Number:* Required

Utility System(s) to be shut down:

Electrical
Gas
Water
HVAC

Description of work to be performed:* Required

Pre-Construction Meeting required prior to shut down?

Date of meeting:

Check the box for all of the following that are required or are impacted:

Lockout/Tagout
Fire Watch
Confined Space Permit
Fire Alarm System
Fire Suppression System

Impacted Customers Notified?

Environmental Health & Safety Remarks:

Facilities Management Remarks:

Emergency Phone Contact(s) After Hours:

Name 1:

Phone #1:

Name 2:

Phone #2:

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