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FOR WORK NEAR OVERHEAD HIGH VOLTAGE POWER LINES AND CONDUCTORS

This form must be completed by any person, firm, or corporation that desires to carry on any work or activity within ten feet (10’) of overhead energized electrical lines or conductors. Arkansas Code § 11-5-307. The ten feet clearance applies to any part of any machinery, equipment or materials, as well as any employee or person.
Company/Individual Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Name and Title of person filing report
Date Work to be Performed
MM slash DD slash YYYY
Expected Date of Completion
MM slash DD slash YYYY
Has the operator of the electrical lines been notified?
- Yes
- No
IMPORTANT Arkansas Code § 11-5-307 also requires written notice to the owner or operator of the electrical lines. You must also make appropriate arrangements with the operator of the electrical lines before proceeding with any work which would violate the ten feet clearance requirement.

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