Thanks to visit codestin.com
Credit goes to www.scribd.com

Scribd
Upload
406 views1 page

Permit To Work

This work permit authorizes non-routine work from 9:00 AM to 5:30 PM between specified dates. It identifies the job executor and location. Hazards are identified relating to electrical work, confined spaces, heights, hot work, excavation, mobile cranes, compressed air, and hydraulics. Required PPE like harnesses and masks are specified. Permits for electrical work, confined spaces, heights, hot work, and excavation may be needed. Process isolation clearance is required if applicable. Authorizing signatures are needed from the applicant, reviewer, and releaser. The accepted person acknowledges the work scope and safety methods and will only perform authorized work. Extensions require re

Uploaded by

mool raj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
406 views1 page

Permit To Work

This work permit authorizes non-routine work from 9:00 AM to 5:30 PM between specified dates. It identifies the job executor and location. Hazards are identified relating to electrical work, confined spaces, heights, hot work, excavation, mobile cranes, compressed air, and hydraulics. Required PPE like harnesses and masks are specified. Permits for electrical work, confined spaces, heights, hot work, and excavation may be needed. Process isolation clearance is required if applicable. Authorizing signatures are needed from the applicant, reviewer, and releaser. The accepted person acknowledges the work scope and safety methods and will only perform authorized work. Extensions require re

Uploaded by

mool raj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
You are on page 1/ 1

WORK PERMIT Permit SR.No.

004
Work Permit for non routine activities - Severity A( ), B( ), C ( ) Working Time - 9:00 AM To 5:30 PM
To be filled in by Job Supervisor/ Engineer
Permit Valid from …………….. To …………., if Job supervisor changed then their signature should be incorporated in the format
Job Executor Name: Sig.: Date: Time: Department:

Description of work

Equipment No
Location
A Action Taken by Executor : Please write Yes or No in the box provided.
Sr. No. Hazard Identification of Non routine activity Yes/No Remarks
1 Electrical
2 Confined area
3 Height Work
4 Hot Work
5 Excavation work
6 Mobile Crane
7 Compressed Air
8 Hydraulics
9
10 Wheather HIRA available of performing activity ? If Yes √ Not available ×
11 If Available attach copy of PRA /HIRA ( PTW will be allowed after HIRA compliance)
B PPE Required : Please write Yes or No in the box provided.
Sr.No. PPE Yes / No Sr.No. PPE Yes / No
1 Full Body Harness 5 Hand Gloves
2 Ear Plug 6 Apron & Leg Guard
3 Goggle / Face shield 7 Heat Resistance suit
4 Dust Mask 8 Safety Net
5 Life line 9 Other

C Permits Required : Please write Yes or No in the box provided.


Sr.No. Safety Checks for compliance Yes/No If Yes, Permit No. Remarks
1 Is Electrical Work Permit Required ?
2 Is Confined area permit required ?
3 Is Height Work Permit Required ?
4 Is Hot Work Permit Required ?
5 Is Excavation work permit required ?

Name of Concerned
Signature & Date
Process Engineer
Is Process Isolation required ?
6
If YES, take clearance form process Dept.

Authorisation Step Name Signature Date Time


Permit Applicant
Permit Reviwer
Permit Releaser
NOTE:- Name & Signature should be clearly mantioned
Acceptance: To be completed by the person who will carry out the job. Then to be handed back to Releaser .
I understand the work which is to be carried out and the method of work to be used to ensure that it is Signature: Date:
carried out safely . Time:
(Job Supervisor
No work will be carried out other than the work authorized by this permit /Contractor )

Extension / Transfer of permit All checks reviewed & found OK to extend permit
Remarks
Date Name Signature Date Signature Date Signature Date Signature Date Signature
Permit Applicant
Permit Reviwer
Permit Releaser

The above work is completed. Man power deployed is removed from the working Signature: Date:
Completion: site. Time:
(Job Supervisor
/Contractor )
1. This permit Applies only to work in the location described.
Note : 2. This permit only applies to the person to whom it is issued. If work has to be continued by someone else, this permit must be returned to issuer for
cancellation and another permit issued.

Copy : (1) Job Sup./Contractor / Office Record (2) EHS Dept.

You might also like