Hazardous Conditions Permit Application

This permit requires 72 business hours notice.

If this is an emergency, please submit this form and call the Fire Department for assistance.

To be submitted by a UCD representative.

UCD Campus: (530) 752-1236
UCDHS: (916) 734-3036

All bold fields are mandatory.

Some fields that are required were not completed, or an invalid entry was entered. Required fields that are not completed are marked with a red line, and invalid fields are marked with a green line.

Hazardous Conditions Duration

Campus/UCD MC
 Campus  Med Center  
Start date and time
 //  : mm/dd/yyyy
End date and time
 //  : mm/dd/yyyy
Will any work take place on nights/weekends?
 Yes  No   If yes, complete the next section. If no, skip the next section.

Work on Nights and Weekends

 Only complete this section if work will occur on nights and weekends 
Start date and time:
 //  : mm/dd/yyyy
End date and time:
 //  : mm/dd/yyyy
Name of the designated Firewatch, if applicable.
UCD Department or Company Name
Phone number of the designated Firewatch, if applicable.

Permit Information

Type of permit requested
Permittee name
UCD Department or Company Name
Permittee title
Permittee phone number
Permittee fax number
Email address
Project name
Project number
Please enter 'NA' if not applicable.
Responsible campus department
 
Campus project manager/contact
PM/Contact Phone number
Are you using a contractor?
 Yes  No  
If yes, please give their business address below.
Address line 1
Address line 2
City
State
Zip

Work/Event Information

Location of work/event
Please indicate a building and room description/number.
 
Description of work/event
Has Campus Project Manager coordinated work with Fire Alarm Shop?
 Yes  No  
If yes, please complete the two questions below.
Is a fire alarm shutdown required?
 Yes  No  
Work Order # for fire alarm assessment/shutdown

A confirmation number will be generated after submitting form. Please keep this number for reference.

Pending verification of information, a permit will be faxed to you for signature within 72 hours of the work/event.

Permit is not valid until the UCD FD has received a copy of the permit with your signature.