Attachment 1: Airfield Construction Waiver

AIRFIELD CONSTRUCTION WAIVER APPLICATION FORM

1. Project or Work Order #

2. Contract #

3.Waiver # (Government Use Only)

INSTRUCTIONS: Requester MUST complete blocks 1, 2, 4-6, 8,10,11, if not applicable put N/A in the block. 4. Include a map with a detailed depiction of the construction location and submit with this form. 5. Description of Construction Activity: Include description of construction with notes pertaining to the work that will be done.

6. Facility Number (Closest to Construction Activity):
7. CRITERIA TO BE WAIVED (Government Use Only- State Chapter, paragraph, table number, etc. from UFC 3-260-01 or other):

Longitude:

N

Latitude:
A) Construction Activity Ground Elevation (Average Mean Sea Level):

W
Ft.

B) Tallest Construction Equipment Height (Crane Height, etc):

Ft.

Total Height (A+B):

Ft.

8. Location and Height Data of Construction Activity:

9. Why is the temporary waiver required?

h of c

10. Point of Contact Data:

CEC (THDR, Alutiq,etc.) Project Manager:

Phone & Email:

Contractor (Executing the work):

Phone & Email:

Construction Start Date:

Construction End Date:

11. Describe risk mitigation measures that will be taken for each violation/waiver. (eg. Special painting, obstruction lighting, barricades, marshallers, flagging, safety plan/recall procedures, etc.)

12. COORDINATION COMPLETED (Government Civil Engineering Use Only):

GROUND SAFETY

72 ABW/SEG

AIRFIELD OPERATIONS 72 OSS/OSA

LOGISTICS

72 LRS/DD

TERPS

HQ AFMC/A3

COMMUNICATIONS 72 CS/SCX

FLIGHT SAFETY

72 ABW/SEF

SECURITY FORCES 72 SFS/S5S

AIRFIELD MANAGER

72 OSS/OSAM

13. APPROVAL (Government Use Only) Installation Commander approval authority. If waiver is an emergency the Base Civil Engineer may approve according to UFC 3-260-01, B1-2.5.4.7.

Installation Commander

(Base Civil Engineer if Emergency)

Form Date: April 2018