CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

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BPA F 6410.42e

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

(09-2025)

OMB Control
Number: 1910-5203
Expiration Date:
7/31/2027

Page 1 of 3
Permit shall be posted on Job Site and kept for 1 year after job completion.
1. Facility/Station:
2. Room/Area
3. Contract Worker (name)

4. Work Phone Number

5. Extended Duration

6. One-time Use Only

7. Contract Supervisor (name)

8. Work Phone Number

9. Start Date

10. Expiration Date

11. Description of work to be done
12. Description of Circuit/Equipment
13. Justification for why equipment cannot be de-energized
Shock Hazard Analysis
15. Limited Approach Boundary

14. Maximum Voltage
17. Insulated Tools/Equipment Rating

19. Incident Energy Level (Cal/cm2)

16. Minimum Approach Distance

18. Glove Rating/Class
Arc Flash Hazard Analysis
20. Arc Flash Boundary
22. ATPV Rating Cal/cm2

21. Arc Rated Clothing Worn

23. Safety Checklist (if items are not checked justification shall be provided)
All Workers involved must be trained, qualified, and have full knowledge of equipment being worked on.
A minimum of one additional Qualified Electrical Worker is required. This person must be able to de-energize all power
sources and have immediate access to a telephone or radio to call EMS in case of emergency.
Necessary personal protective equipment to safely perform the assigned task.
Remove all jewelry and metal apparel.
Means employed to restrict the access of unqualified persons from
Documented job briefing including discussion
the work area (barricades/warning signs):
of any additional job-specific hazards.
Electrical Contact Accident Protocol reviewed and available:
Justification:
24. Contract Qualified Electrical Worker Performing Hazard Analysis (name)

24a. Date

25. BPA District Engineer or Substation Operations Representative (name and signature)

25a. Date

26. COTR (name)

Approvals (must be signed prior to start of work)
26a. Date
27. Prime Contract PM (name)

28. Supervisor (signature)
Printed or typed name(s)

27a. Date

28a. Date
29. Additional Workers Involved (understands and agrees to the above)
Signature(s)

File Code: FE-1100; Retention: Destroy when no longer applicable.

Date(s)

BPA F 6410.42e
(09-2025)

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

OMB Control
Number: 1910-5203
Expiration Date:
7/31/2027

Page 2 of 3
Instructions
BPA’s intent with the Contract Energized Electrical Work Permit is to ensure that all work is conducted de-energized whenever
possible.
1. Facility/Station: This is the general location of the work. Example: substation name, building name, etc.
2. Room/Area: This is a more specific description of where the work is taking place. Example: Relay House 1, Control House,
Second floor hallway etc.
3. Contract Worker: Enter the person’s name who will be performing the work.
4. Work Phone Number: Enter the phone number to be used to contact the person performing the work. It may be the
supervisor’s phone number if the employee does not have a phone.
5. Extended Duration: Check this box if the work will be occurring for more than one workday. DO NOT FILL OUT A SINGLE
PERMIT FOR MULTIPLE JOBS. Each job requiring a permit will need a separate permit. Example: replacing or adding several
molded case breakers into a single panel requires 1 permit. Replacing or adding molded case breakers into separate panels
requires a permit for each panel.
6. One-time Use Only: Check this box if the work is expected to be completed on the same day. Note if the work extends
beyond a single day go back and check the extended duration box and note that the work was extended. A new form does
not need to be completed.
7. Contract Supervisor: The name of the direct supervisor of the requestor.
8. Work Phone Number: The direct supervisor’s phone number. This may be the same as the number entered for number 4 if
the supervisor’s number was provided there.
9. Start Date: The date that the actual work requiring the permit started.
10. Expiration Date: This is the date when the work is expected to end. If the work continues past the expected date a new date
may be entered by hand. The permit does not actually expire until the work is deemed complete.
11. Description of the work to be done: Self-explanatory; enter information about the scope of the job requiring the permit.
12. Description of Circuit/Equipment: Enter as much information as needed to understand the limits/parameters of the work.
Example: replacing a bad order ACB in 480V panel PL-4.
13. Justification of why equipment cannot be de-energized: This should be as detailed as possible. It should not read, “No
feasible”, “Operator said no”, or “Dispatch would not allow”. Example: “De-energization of the station service panel YP-2
would require the entire station to be run on batteries. On the last battery maintenance cycle, the station batteries were
found to be in need of replacement and should only be relied upon for emergencies. Batteries are scheduled to be replaced
but this work cannot wait for the replacement due to critical loads.”
14. Maximum Voltage: This is the highest nominal voltage rating of the equipment covered under the permit. It is usually found
on the arc flash label. If the work involves a transformer, then the high side voltage should be noted.
15. Limited Approach Boundary: This is the distance which unqualified individuals must be kept from crossing without an
escort. It protects against shock hazard. This or the Arc Flash Boundary (whichever is greater) will be used to determine your
barricade distance.
16. Minimum Approach Distance: The distance which qualified individuals must maintain without one of the five provisions in
the APM Rule M-1 being in place.
17. Insulated Tools/Equipment Rating: This is the voltage rating of insulated tools or barriers used to prevent contact with
energized parts.
18. Glove Rating/Class: This is the rating of the glove the worker is using to prevent accidental contact. Remember, there are
different ratings for AC and DC. Also, if the glove is used without a leather protector it must be derated by 50% or 1 voltage
class, whichever is greater. The glove must also be electrically retested before being used at full voltage and may not be used
if there is a possibility of puncture or damage.
19. Incident Energy Level (Cal/cm2): This is the calorie rating of the circuit being worked. It can be found on the affixed label or
acquired from the BPAHotStickCurves (Dynamic Use) spreadsheets.
20. Arc Flash Boundary: This is the distance that the incident energy is 1.2 calories/cm 2 or less. It can be found on the affixed
label. It is the second factor used in determining where the barricade distance must be established to prevent unqualified
workers from entering into the work zone. NOTE: Unqualified workers may be escorted into the limited approach boundary
but may NOT enter the arc flash boundary without all of the proper PPE as required for the incident energy.
21. Arc Rated Clothing Worn: This is the clothing that will be required to meet or exceed the incident energy level. If layering is
used list all layers of clothing.
File Code: FE-1100; Retention: Destroy when no longer applicable.

BPA F 5480.40e

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

ENERGIZED ELECTRICAL WORK PERMIT

(09-2025)

OMB Control
Number: 1910-5203
Expiration Date:
7/31/2027

Page 3 of 3
22.

23.

24.
25.
26.
27.
28.

29.

ATPV Rating Cal/cm2: List the rating of the clothing worn. If layering is performed, list the total APTV rating of the layered
system or the rating of the outermost layer if it exceeds the incident energy. This rating must meet or exceed the incident
energy.
Safety Checklist Items: All items must be checked and discussed as part of the pre-job briefing. If any item cannot be met
provide justification in the space provided. Any items not checked will require Supervisory and Organizational Manager
approval prior to work.
Qualified Electrical Worker (QEW) Performing Hazard Analysis: This is the name of the QEW who performed the Shock and
Arc Flash Hazard analysis. It does not have to be the individual who will be performing the work.
BPA District Engineer/Substation Operations Representative: This is the signature and name of the person who confirmed
that the work must be performed energized.
COTR: This is the signature of the Contract Officer’s Technical Representative for the contract.
Prime Contract Project Manager: This is the project manager for the prime contractor for the project.
Supervisor: This is the signature of the supervisor for the person performing the work. This signature may be signed as
verbal consent given. This cannot be given as a third-party approval. If the same individual as question 27, write in “same as
#27”.
Additional Workers Involved: List all workers who will be inside the arc flash boundary while the work is being performed.
Each name listed shall also have a signature that the individual agrees with the information on the form. Any worker who
does not wish to sign may not be allowed into the arc flash boundary until the work has been placed into an electrically safe
work condition.
Paperwork Reduction Act Burden Disclosure Statement

This data is being collected to ensure the safety of BPA’s contract workers. The data you supply will be used by BPA to validate
equipment cannot be de-energized by BPA engineers or substation operators before a contractor is allowed to work on energized
equipment. Public reporting burden for this collection of information is estimated to average .25 hours (15 minutes) per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining that data needed, and
completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22,
Paperwork Reduction Project (OMB control number 1910-5203), U.S. Department of Energy, 1000 Independence Ave SW,
Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (OMB
control number 1910-5203), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of
Management and Budget (OMB) before undertaking a collection of information directed to 10 or more persons of the general
public, including persons involved in or supporting the operations of Government-owned, contractor-operated facilities.
Submission of this data is mandatory.

File Code: SM-1300; Retention: Destroy 10 years after the records are closed.