GLENMARK LIMITED

[SR][SMS][C020201] GENERAL WORK PERMIT

IN CASE OF EMERGENCY DIAL: Permit No.
Routing of Permit
Permit Initiator/Owner → Permit Executor → HOD of Permit Ini ator → HOD of Executor →Safety Champion/ EHS representa ve
Department: Equipment No.(if any)
Area
Brief description of work:

Permit Validity Date From To

Time From To
HAZARDS IDENTIFIED [JOINTLY BY MANAGER OF CONCERNED DEPARTMENT, MANAGER - PLANT ENGINEERING, PERMIT EXECUTOR, PERMIT OWNER]
[ ] Corrosive Chemical [ ] Hot Materials [ ] High/ Low Temp. [ ] Traffic [ ] Fragile roof
[ ] Flammables [ ] Steam [ ] Live Electrical [ ] Confined space [ ] Lone work
[ ] Explosives [ ] Compressed gases [ ] Overhead Danger [ ] Lack of oxigen [ ] Buried cables
[ ] Compressed gas [ ] Fumes/ dust [ ] Moving machine [ ] Use of scaffold [ ] Buried pipelines
[ ] Risk to nearby area/ process/ operation [ ] Auto-start equipment [ ] Unsafe access [ ] Other (specify)

PPE TO BE USED
[ ] Helmet [ ] Handgloves (Elect) [ ] Apron [ ] Gas Mask
[ ] Safety shoes [ ] Handgloves (Other) [ ] PVC Overall [ ] SCBA
[ ] Gum boots [ ] 4 [ ] Ear Plugs/ Muffs [ ] Safety Belt
[ ] Handgloves (PVC) [ ] Face Shield [ ] Dust Mask [ ] Safety net

ISOLATIONS REQUIRED: Requested by "PERMIT OWNER": ____________

(A) Electrical including motor isolation: YES/NA (B) Services isolation: YES/NA ( C) Process isolation: YES/NA
Drive/panel involved: Service involved: Steam/ Air/ Water/ Other(specify) Equipment Involved:

How isolated (Specify):

[ ] Fuse removed: [ ] Valve closed & tagged [ ] Depressurised: [ ] Material drained: [ ] Tested Non-operative:
[ ] Isolator put off & locked: [ ] Line blanked: [ ] Flushed: [ ] Line disconnected:
NAME SIGNATURE DATE TIME
Certified by electrician
Certified by operator
Certified by Senior Officer-Plant Engg/ Executive of
Certified by Senior Officer/ Executive of concerned
PRECAUTIONS CHECKLIST:
(A) General (Applicable for all jobs)
[ ] Job site checked [ ] Underground cable checked [ ] Provide separate Method
[ ] Area cordoned [ ] Underground pipe checked [ ] Statement for tasks like:
[ ] Caution boards displayed [ ] Shoring arrangement done [ ] Demolition
[ ] ELCB for portable tools [ ] Method statement for > 1.5 M [ ] Work on live electrical
[ ] PPE provided [ ] High Elec. Voltage area
[ ] Lifting tools certified [ ] Moving heavy equipment
[ ] Supervision provided [ ] Others
Name of the Agency carrying out the work: Agency Supervisor Name
Total No. of Person carrying out the job Name of all thos persons
Declaration from Agency Supervisor- I on behalf of my agency declare that I have fully understood the nature of job, hazzards involved and Safety requirement for the same. I will fully adhere to the
Safety norms written in this permit before, during and upon completion of the stated work. All the above persons are free from any ailment such as vertigo, epilepsy and low/high blood pressure.

Name and Signature of Agency Supervisor ________________________

This is to certify that I have checked the safety precautions as per the checklist for carrying out the work & found to be adaquate & safe and all concerned person have been explained the above
precautions
Name of permit initiator / owner Signature
Name of permit intiator / owner's HOD Signature
Name of permit executor Signature
Name of permit executor's HOD Signature
Name of Safety Champion / EHS representative Signature
This is to certify that I have checked the safety precautions as per the checklist for carrying out the work & found to be adaquate & safe and all concerned person have been explained the above
precautions
Name & Signature of New permit responsible person due to shift change over
Name & Signature of New permit responsible person INITIATOR INITIATOR HOD EXECUTOR EXECUTOR HOD Safety Champion / EHS representative
due to shift change over
Name
Signature
IN BETWEEN CHECKS
NAME OF PERSON CHECKING THE PERMIT Signature Remarks
1
2
3
 (TO BE PRINTED ON BACKSIDE OF THE PERMIT)
TO BE USED ONLY IN CASE OF PERMIT EXTENSION(AFTER 1730 HRS BUT TO BE TAKEN PERMISSION BEFORE 1700 HRS)
Name of new / old permit initiator / owner Signature
Name of new / old permit initiator / owner's HOD Signature
Name of new / old permit executor Signature
Name of new / old permit executor's HOD Signature
Name of Safety Champion / EHS representative Signature
TO BE USED BY THE PROJECT ONLY APPLICABLE FOR THE NEW PROJECTS SITE ONLY
Date
Time : From
Time : To
Name of permit initiator / owner
Signature
Name of permit executor
Signature
Name of permit initiator / owner's HOD
Signature
Name of permit executor's HOD
Signature
Name of Safety Champion / EHS representative
Signature
Name of agencies Supervisor
Signature
TO BE USED ONLY IN CASE OF PERMIT EXTENSION (AFTER 1730HRS BUT TO BE TAKEN PERMISSION BEFORE 1700HRS)
Date
Time : From
Time : To
Name of permit initiator / owner
Signature
Name of permit executor
Signature
Name of permit initiator / owner's HOD
Signature
Name of permit executor's HOD
Signature
Name of Safety Champion / EHS representative
Signature
In Case of Closure of the permit
Routing of Permit
Permit Initiator/Owner → Permit Executor → HOD of Permit Ini ator → HOD of Executor →Safety Champion/ EHS representa ve
In Case of closure of the job work permit
Status of Job : Job completed / Job not completed
If Completed then, complete following instruction:-
The job completed on _______________at__________________hrs.
Handed over by Working Agency Supervisor Name__________________Signature_________________
Handed over to Name__________________Signature_________________
Name of Verifying Person ____________________Post___________________Signature______________
To be checked and filled by the Handing over Person Yes / NA Name Signature
1 Has the area / equipment made clear from all debris, tools, equipment, scrap or any unwanted material before handling over the
2 Is the Lock out Tag out removed and all forms of energy restroed?
3 Are the machine guards / Safety Interlocks / nut-bolts / jumpers back in place?
4 Is the fire extinguisher removed from the area?
5 Any other Remarks / Observation :