ENERGIZED ELECTRICAL WORK PERMIT

Project Name
Permit Duration

Bus ID 230-SG-911
Job/Work Order Number 12345

MINERA SAN CRISTBAL S.A.

From: 08/01/2015
To: 08/02/2015

PART I: TO BE COMPLETED BY REQUESTER

1. Description of circuit/equipment location Sala 230BL271
2. Description of work to be done: Limpieza de interruptor
3. Justification of why the circuit /equipment cannot be de-energized or the work deferred until the next scheduled outage: Nivel de tension
elevado el personal no puede trabajar en caliente

Title

Name

Signature

Date

Limbert Gomez

Trabajo en vivo

08/02/2015

PART II: TO BE COMPLETED BY ELECTRICALLY QUALIFIED PERSONS DOING THE WORK

Check When
Completed

1. Detailed job description procedure to be used in performing the above detailed work: Limpieza de MCC
2. Description of the safe work practices to be employed: Uso de EPP aducado segun valor de energia incidente
3. Results of the Shock Hazard Analysis
4. Determination of Shock Protection Boundaries:
5. Results of the Flash Hazard Analysis:
6. Determination of the Flash Protection Boundary
7. Necessary personal protective equipment to safely perform the assigned task:
8. Means employed to restrict the access of unqualified persons from the work area:
9. Evidence of completion of a Job Briefing including discussion of any job-related hazards:
Bus ID 230-SG-911

Equipment Name

Arc Flash Hazard Analysis

Shock Hazard Voltage

Shock Hazard Analysis

11 kV

Prohibited Approach Boundary

0,2 m

V-Rated Gloves Class

Glove V-Rating

17000 VAC

Incident Energy

4,77 cal/cm

Restricted Approach Boundary

0,7 m

Arc Flash Boundary

3,8 m

Limited Approach Boundary

1,5 m

Work Distance

91,4 cm

Energy Level

Level C

PPE - FR long-sleeve shirt (minimum arc rating of 4), worn over untreated cotton T-shirt with FR pants (minimum arc rating of 8)

Do you agree the above described work can be done safely? Yes
Title

Name

(If no, return to the requester)

Signature

Date

Trabajo en linea viva

Serapio Copa

08/01/2015

Trabajo en linea viva

Esequio Espinoza

08/01/2015

This form is based on NFPA 70E, 2012

Page 1 of 3

ENERGIZED ELECTRICAL WORK PERMIT

Project Name
Permit Duration

MINERA SAN CRISTBAL S.A.

From: 08/01/2015
To: 08/02/2015

Bus ID 230-SG-911
Job/Work Order Number 12345

PART III: APPROVAL(S) TO PERFORM THE WORK WHILE ELECTRICALLY ENERGIZED

Title

Trabajo en linea viva

Name

Signature

Limbert Gomez

Date

08/01/2015

Note: Once the work is complete, forward this form to the site Safety Department for review and retention.

This form is based on NFPA 70E, 2012

Page 2 of 3

ENERGIZED ELECTRICAL WORK PERMIT

Project Name
Permit Duration

MINERA SAN CRISTBAL S.A.

From: 08/01/2015
To: 08/02/2015

Identif y
The Hazards
The voltage levels involved
Skills required
Any foreign (secondary source) voltage source

Bus ID 230-SG-911
Job/Work Order Number 12345

The shock protection boundaries

Ask
Can the equipment be de -energized
Are backfeeds of the circuits to be worked on possible?

Is a standby person required?

Check
Job plans
Single -line diagrams and vendor prints
Status board
Information on plant and vendor r esources is up to date

Safety procedures
Vendor information
Individuals are familiar with the facility

Know
What the job is
Who else needs to know Communicate!

Who is in charge

Think
About the unexpected eventWhat if?
Lock Tag Test Try
Test for voltage FIRST
Use the right tools and equipment, including PPE

Install and remove grounds

Install barriers and barricades
What else?

Prepare for an emergency

Is the standby person CPR trained?
Is the required emergency equipment available?
Where is it?
Where is the nearest telephone?
Where is the fire alarm?
Is confined space rescue available?

This form is based on NFPA 70E, 2012

What is the exact work location?

How is the equipment shut off in an emergency?
Are the emergency telephone numbers known?
Where is the fire extinguisher?
Are radio communications available?

Page 3 of 3