Permit PSA FID

Name of Permittee: Application Id:

Contractor # 1 Name: Contractor # 2 Name:

Contractor # 3 Name: Contractor # 4 Name:

Weather Condition: Temperature: °F

District: County:

Traffic Control Checked

Corrective Action Taken?

Any Work Zone Traffic Control Corrective Action? Instructions to Permittee and corrective action taken, if required

Hours Worked Start time (HH:MM)

Odometer Start

Hours Worked Stop time (HH:MM)

Odometer End

Name of Visitors

Equipment Used

Qty Power Tools Qty Hand Tools Qty Trucks Qty Motorized Qty General

Air Compressor Blasting Drill Articulating Dump

Aerial Work Platform Arrow board

Air tools Broom – Power Auger/ Bucket Auto – Grader Compressor

Bender- Rebar/conduit

Brush Cutter Bucket Truck Backhoe Concrete Buckets

Brush Chipper Cable Skidder Distributor Bulldozer Generator Chainsaw Cutting Torch Euclid Bulldozer w/ripper Gradeall

Concrete Pump Disc Grinder Flatbed Crane Light Plant Concrete Vibrator Electric tools Hydro

demolition Drill Rig - Caissons Message Board

Jackhammer Grinder Hydroseeder Drill Rig - Well Pan Milling Machine Hand tools Low Boy Excavator Roller - Pneumatic

(Rubber Tire) Mulch Blower Hoe Shaker

head Paint Line Grader – Roadway Roller - Vibratory - Double Drum

Pressure Washer Hoe-pac Pickup High Reach Lift Roller - Vibratory - Oscillation

Rubblizer Tamper - Hand Pole Hoe Ram Roller - Vibratory - Single Drum

Sandblaster Pole Pounder Material transfer Vehicle Roller-Rubber Tire

Saw – cut-off Rock Truck Mini - Excavator Roller-Sheepsfoot

AM PM

Permit#

Meal Duration:

AM PM °F PM AM

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Tack Buggy Single Axle Dump Paver – Asphalt Roller-Static

Trencher Tandum Axle Dump Paver – Concrete Roller-Walk Behind

Vibratory Plate Tool Paver – slip form Safety Boat Welder Track Loader Pile driver Spreader Box

(Aggregate)

Tractor (farm) Pile Vibrator Steel Plates

Tractor Trailer Power Screed (Bidwell)

Trash Pump

Trailer Saw – Trench Wheel (Vermeer)

Trench Box

Tri-Axle Dump Saw – Walk behind

Truck - Crash Skid Steer

Van Tar Buggy

Water Track Hoe

Water Pump / hose

Widener

Labor ClassificationsQty Labor Class Groups Qty Operator

Group Qty Equipment

Operators Qty Skilled Qty General

General Group 1 Mucker Carpenter Deck Hand

Skilled Group 2 Pile Driver Carpenter/Welder Foreman

Luteman, screed Group 3 Pile Driver/Welder Cement Mason Laborer

Rebar tie Group 4 Truck Driver Electrician Landscape Labor

Pipeline welder Group 5 Class 1 Electric Lineman Nipper

Flag person Class 2 Finisher Oiler

Toxic Hazardous Class 3 Ironworker Painter - Structural

Owner Miner Painter – Brush

Welder Painter – Spray

Surveyor Permittee Inspector

Nuclear Technician Superintendent

Concrete technician

PSA Comments

PSA Work – Location Detail

Location 1 Location 2

From To From To Segment(s)

Offset(s)

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Work Description

Inspection Date:(MM/DD/YYYY)

Inspector First Name

Inspector EPS User id

Inspector Last Name

Inspector Email

Notes:Please follow the naming convention to ensure your upload of the PDF into ePermitting <User ID>-<Application ID or Permit Number>-<Inspection date YYYYMMDD>-<Upload Number>.YourEFTID-12345-20160916-1

Version 3 3 05/01/2017