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UTILITY OUTAGE REQUEST

Utility System Shut Down/Interruption Assessment

Assessment to be completed by Contractor representative.

Assessment to be approved by Facilities Director and Bond Project Manager before outage is to

occur.

Utility Outage Request shall be submitted 15 days prior to scheduled interruption

Contractor shall not contact Campus personnel without the Facilities Director and/or Bond

Project Manager authorization.

Shut Down or Interruption:

Location Campus): _____________________________ Date: ____________

Start Time: __________ End Time: ________ Duration: _________

Utility Systems Affected:

___Electrical

___Water

___Sewer

___Elevators

___Natural Gas

___Fire Alarm

___Fire Detection

___Fire Extinguishing

___HVAC

___Voice Communication

___Data Systems

___Fire Suppression

Areas Impacted by Shut Down/Interruption:

Contact Information & Phone Numbers:

Contractor Company and Representative:

Canutillo ISD Contact: Edgar Goytia (915) 241-7909

Permit Requested by:

Principal

Date:

Permit Authorized by:

Director Facilities

Date:

Permit Authorized by:

Maintenance Supervisor

Date:

Permit Authorized by:

IT Director

Date:

Permit Authorized by:

Bond Project Manager

Date:

Permit Authorized by:

Food Service Director

Date: