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Work Permit Format - 1

This document is a work permit form that outlines the details of a subcontractor's work, including work order and permit numbers, location, work schedule, and safety equipment required. It emphasizes the responsibility of the subcontractor to adhere to safety precautions and includes sections for authorization signatures and completion verification. Additionally, it addresses the need for specific permits related to electrical or confined space work.

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krishnakumar T K
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80 views3 pages

Work Permit Format - 1

This document is a work permit form that outlines the details of a subcontractor's work, including work order and permit numbers, location, work schedule, and safety equipment required. It emphasizes the responsibility of the subcontractor to adhere to safety precautions and includes sections for authorization signatures and completion verification. Additionally, it addresses the need for specific permits related to electrical or confined space work.

Uploaded by

krishnakumar T K
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Work Order No.: _________________ Work Permit No.

: ____________________________
Location: _________________
WORK PERMIT Issue Date: ____________________________

SUBCONTRACTOR ____________________________________AREA OF W ORK ______________________________________

WORK STARTING DATE _______________ TIME __________ WORK ENDING DATE _____________ TIME ________________

DESCRIPTION OF THE W ORK _______________________________________________________________________________


___________________________________________________________________________________________________________

WORK EQUIPMENT _________________________________________________________________________________________


SUBCONTRACTOR
TO BE FILLED BY

___________________________________________________________________________________________________________
Subcontractor receiving Authority _ _ _ Date Time _ _

Subcontractor performing Authority ______________________________________________ Date ________ Time __________

The above signing person is responsible to ensure the work is performed under all the mentioned and required safety precautions.
Failure on this will be subject to disciplinary actions.

INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X):


□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves
□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask
TO BE FILLED BY CONTRACTOR

□ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness
□ Dust Mask □ □ □ □ __________

COMMON PROTECTION EQUIPMENT _________________________________________________________________________


__________________________________________________________________________________________________________

OTHER SAFETY MEASURES _________________________________________________________________________


__________________________________________________________________________________________________________

Contractor Issuing Authority ___________________________________________________Date ________ Time _________

Is Electrical PTW required Is Confined Space PTW required In case Electrical or Confined Space PTW is
YES ___ NO ___ YES ___ NO ___ required? YES ___ NO ___
PTW Number PTW Number If yes, attach a Copy.

Site Preparation completed and work can commence. I understand the precaution to be taken as described above.
Contractor Operating Authority Sub-Contractor Operating Authority

SANCTION AUTHORIZATION SIGNATURES


DATE TIME

The Work is completed and working area cleared The Site has been checked and working Area accepted

_____________________________________ ________________________________________
CLOSURE

Subcontractor performing Authority Contractor Operating Authority

Attachment 1. Your Company Name Work Permit Forms

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