Ehs use only

A. Company Name and Billing Address:

Company Name Company Address
B. Date(s):
Start: Start Date & Time End: End Date & Time
C. Name of Person Responsible for Fire Watch:
Name Contact Info (Cell & Location)
D. Address where Fire Watch is Performed:
     
E. Specific Location of the Fire Watch::
     
F. Purpose of Fire Watch being Performed:
     
I verify the above location has been examined, the designated Fire Watch personnel are qualified and informed of the duties of Fire Watch, and permission is requested to proceed with the work.
Signed: (Applicant)
	DESIGNATED FIRE WATCH PERSONNEL
Fax completed form to: [phone] before start of work.	Name:      
Permit Expires: ( by EHS)	Name:      
Date:      	Name:      
This permit is issued by University of South Florida Environmental Health and Safety Division. This, and all permits, is subject to a permit fee. Jobs are subject to inspection and may be terminated at the discretion of the Fire Safety Specialists if precautions are not in place.	Name:      
	Name: