SUMMARY OF WORK PERMIT CHECKLIST
S No Checklist No
1 KF/FMS/WP(Gen)/01
2 KF/FMS/WP(HW)/02
3 KF/FMS/WP(CS)/03
SUMMARY OF WORK PERMIT CHECKLIST
Description
Work Permit (General)
Work Permit (Hot Work)
Work Permit (Confined Space)
CHECKLIST
Remarks
As and when required
As and when required
As and when required
Knight Frank (India) Pvt. Ltd
Revision No: 03
Revision No: 18.04.2019 KF/FMS/WP(Gen)/01
Work Permit (General)
Permit No. Date:
Permit Issued to: Time Work started:
Area:
Description of Work
Permit is valid from to . ( Write the time )
Note: The permit is valid for one day only. If the work is carried over to the next day a fresh permit to be issued.
Special safety instructions if any:
Safety Equipment Requirement ( Tick the applicable items)
Safety glasses Dust masks Barricades Ear plugs
Goggles Safety belts Barrier tape Others (list )
Face shield Scaffolds & ladders Fire extinguishers
Helmets Warning signs Locks / tags
Checks for jobs at height more than 2 meters Yes No NA
1 Are the persons working have proper safety belts and helmets?
2 Is the scaffolding/ladder safe and secured properly?
3 Is the area of work barricaded?
4 Is a signage 'Work in Progress' displayed prominently?
5 Is the supervisor available to be present through the execution of the work?
Checks for LOTO (Lockout / Tagout)
1 Have electrical power sources been identified, disconnected with appropriate locks and
tags applied and tested?
2 Do all disconnects have the capability of being locked out?
3
Have miscellaneous power sources been identified, deactivated, locked and tagged?
4 Are their circumstances in the course of the job where it is absolutely necessary to
energies the machine with their guards removed?
5 If yes to 4 above, have special instructions been provided to do this job safely and
controlling access to other persons?
6 Are their circumstances in the course of this job for electricians to troubleshoot energized
electrical apparatus?
7 If yes to 6 above, have special instructions been provided to do this job safely and
controlling access to other persons?
Checks for Line breaking for hazardous material
1 Have the line contents been identified? If not, work cannot be started.
2
Have all associated pumps, compressors and computer overrides been out and tagged?
3 Has the line been isolated upstream of the line break by double block and bleed (1st
choice ), double block or blank?
4 Are the persons using appropriate personal protective equipment?
5 If there is any possibility of reverse flow, has the line been isolated downstream of the line
break?
6 Has the line been depressurised and drained of residual contents?
7
Has the line been drained of hazardous materials (e.g. acids, bases, solvents etc.)
8 Has the MSDS of the material in the line or the material used to wash out the line been
consulted and made available at the work site?
Warning: Smoking / Tobacco in the premises is strictly prohibited.
9
Is a respirator required? State the respirator and cartridge type on the work permit.
10 Has the area been isolated with warning tape or barricade?
Warning: Smoking / Tobacco in the premises is strictly prohibited.
General checks applicable to all types of jobs
1 Are all hand tools to be used in order?
2 Have the workers been informed about the emergency procedure?
3 Are all temporary electrical connections give safe and have been done by using proper
lugs, plugs and sockets and connections tightened?
4
Is it required to impair the Fire Alarm system? If so follow the impairment program.
Particulars of the work crew
Name Signature Name Signature
Certificate by the Vendor/Vendor's supervisor Certificate by the KF Shift engineer/Asst. FM
I have checked the area and have thoroughly checked the points
I have checked the area and have thoroughly checked the points
given in the checklist above. I have verified that the work crew are
given in the checklist above. I have instructed my work crew on
aware of how to carry out the job safely and how to use the safety
how to carry out the job safely. I will ensure that the safety
equipment. The job can be carried out safely and Work permit can be
instructions are followed throughout the execution of the job.
issued.
Signature Time: Signature Time: Signature
Date: Date: Date:
Certificate by the Authority issuing the work permit
Certified that I have personally checked the area, the safety and the equipment and consider it safe to carry out the work. If at any stage
it is found that the safety measures are being violated the work will be suspended with immediate effect.
Signature of person issuing the permit.
Date: Time:
Time Work completed:
All the tools have been removed from the place of work.
The area is clean and cleared of all material, waste / dirt.
Work has been completed safely and there is no injury to any person and no damage to any equipment/material.
Signature Signature Signature
(Vendor) (KF Shift engineer/Asst. FM) (Issuing authority)
Procedure for issuing Work permit
1 This work permit is required for all jobs such as maintenance work on equipment ( pumps, fire hydrant system, DG sets,
refrigeration system, electrical system etc.) working at heights, line breaking for hazardous material etc. Separate work permits are
required to be issued for hot work and working in confined space.
2 The work permit should be made in duplicate. One copy will be given to the supervisor undertaking the job and will be retained by
him at site during the execution of the job. The second copy will be retained by the issuing authority.
3 The Facility Manager is authorised to issue the work permit.
4 The work permit will be filled by the vendor carrying our the job, reviewed by the KF shift engineer/ Asst. FM and then Facility
Manager will verify all the points and then issue the work permit.
5 Work permit will be issued for one day. It will be reviewed/revalidated when the shift is changing. A fresh work permit will be issued
if the work is to be continued on the next day.
Warning: Smoking / Tobacco in the premises is strictly prohibited.
6 After completion of work the permit will closed and submitted to the issuing authority before leaving the site.
Warning: Smoking / Tobacco in the premises is strictly prohibited.
Knight Frank (India) Pvt. Ltd
Revision No: 03
Revision No: 18.04.2019 KF/FMS/WP(HW)/02
Work Permit (Hot Work)
Permit No. Date:
Permit Issued to: Time Work started:
Area:
Description of Work
Permit is valid from to . ( Write the time )
Note: The permit is valid for one day only. If the work is carried over to the next day a fresh permit to be issued.
Special safety instructions if any:
Safety Equipment Requirement ( Tick the applicable items)
Safety glasses Dust masks Barricades Ear plugs
Goggles Safety belts Barrier tape Others (list )
Face shield Scaffolds & ladders Fire extinguishers
Helmets Warning signs Locks / tags
Checks to be carried out Yes No NA
1 Have all flammable or combustible material removed from the work site area (at least 35
feet away)?
2 If the floor is combustible, has it been wet down or completely covered within 35 feet of the
job?
3 Have flammable or combustible materials that cannot be relocated been protected with
flame-proof barriers?
4 Has the use of flammable materials in the area been stopped?
5 If pipelines containing flammable materials run through the area, are they verified to be
leak-free & protected from impact?
6 Have all vents & intakes within 35 feet of work site that could disperse or intake
flammables been isolated?
7 Have floor drains within 35 feet been sealed off or where they could disperse or intake
flammables been isolated?
8 Are appropriate / adequate fire extinguisher available and ready for use ? Note: Installed
fire extinguishers are not considered adequate.
9 Has a fire watch been assigned? Note: A fire watch must be assigned until 60 minutes
after hot work is completed.
10 If sparks can fall to lower levels, has adequate protection been provided and fire watch
assigned to lower level?
11 If automatic sprinklers exists in the area, are they in service?
12 Does the work crew know the location of the nearest telephone, evacuation alarm, safety
eyewash & shower?
13 Has the work area been isolated from adjacent areas?
14 Are barrier curtains being used to prevent arc reflection?
15 Have vendors been briefed on emergency procedures?
16 Is the Logout / Tagout system used to isolate all types of energy sources?
17 Is proper lighting and proper exit available / provided?
18 Is the welding return connected with the job?
19 Are welding cables in good condition? ( No cuts, no bare conductors exposed)
20 Is adequate ventilation provided to allow welding fumes to be extracted/diluted?
21 Are the required Personal Protective Equipment available in good condition and being
used? ( Face shield, Leather hand gloves, apron, helmet, safety glasses, safety shoes
etc.)
22
Is the grinder guard in position? The job rest and toe gap maintained within 4-6 mm?
Warning: Smoking / Tobacco in the premises is strictly prohibited
23
Is the welding set energised through Earth Leakage circuit breaker(ELCB) / and earthed?
24 Are the gas cylinder mounted on trolley secured and capped?
25 Is the gas hose pipe in good condition, tested and Is color code?
26 Is welding torch provided with flash back arresters?
27 Is proper ladder / scaffold provided and secured?
28 Are the safety belts and lifeline used (where required)?
29 Are all hand tools to be used in order?
30 Have the workers been informed about the emergency procedure?
31 Are all temporary electrical connections give safe and have been done by using proper
lugs, plugs and sockets and connections tightened?
32
Is it required to impair the Fire Alarm system? If so follow the impairment program.
Particulars of the work crew
Name Signature Name Signature
Certificate by the Vendor/Vendor's supervisor Certificate by the KF Shift engineer/Asst. FM
I have checked the area and have thoroughly checked the points
I have checked the area and have thoroughly checked the points
given in the checklist above. I have verified that the work crew are
given in the checklist above. I have instructed my work crew on
aware of how to carry out the job safely and how to use the safety
how to carry out the job safely. I will ensure that the safety
equipment. The job can be carried out safely and Work permit can be
instructions are followed throughout the execution of the job.
issued.
Signature Time: Signature Time: Signature
Date: Date: Date:
Certificate by the Authority issuing the work permit
Certified that I have personally checked the area, the safety and the equipment and consider it safe to carry out the work. If at any stage it
is found that the safety measures are being violated the work will be suspended with immediate effect.
Signature of person issuing the permit.
Date: Time:
Time Work completed:
All the tools have been removed from the place of work.
The area is clean and cleared of all material, waste / dirt.
Work has been completed safely and there is no injury to any person and no damage to any equipment/material.
Signature Signature Signature
(Vendor) (KF Shift engineer/Asst. FM) (Issuing authority)
Procedure for issuing Work permit
1 This work permit is required for all jobs involving hot work in any location except hot work inside confined space in which case a
separate work permit is required with additional precautionary measures.
2 The work permit should be made in duplicate. One copy will be given to the supervisor undertaking the job and will be retained by
him at site during the execution of the job. The second copy will be retained by the issuing authority.
3 The Facility Manager is authorised to issue the work permit.
Warning: Smoking / Tobacco in the premises is strictly prohibited
4 The work permit will be filled by the vendor carrying our the job, reviewed by the KF shift engineer/ Asst. FM and then Facility
Manager will verify all the points and then issue the work permit.
5 Work permit will be issued for one day. It will be reviewed/revalidated when the shift is changing. A fresh work permit will be issued
if the work is to be continued on the next day.
6 After completion of work the permit will closed and submitted to the issuing authority before leaving the site.
7 LPG cylinders are not permitted for gas cutting operation.
Warning: Smoking / Tobacco in the premises is strictly prohibited
Knight Frank (India) Pvt. Ltd
Revision No: 03
Revision Date: 18.04.2019 KF/FMS/WP(CS)/03
Site Name:
Work Permit (Confined Space)
Permit No. Date:
Permit Issued to: Time Work started:
Area:
Description of Work
Permit is valid from to . ( Write the time )
Note: The permit is valid for one day only. If the work is carried over to the next day a fresh permit to be issued.
Special safety instructions if any:
Safety Equipment Requirement ( Tick the applicable items)
Safety glasses Dust masks Barricades Ear plugs
Goggles Safety belts Barrier tape Others (list )
Face shield Scaffolds & ladders Fire extinguishers
Helmets Warning signs Locks / tags
Checks to be carried out Yes No NA
1 Has all piping been isolated by disconnect, blank or double block and locked and tagged?
2 Has all electrical equipment associated with the space been locked out and tagged out?
3 Is the space clean and free of hazardous residue?
4 If not have appropriate safeguards been taken to ensure safe entry?
5 Has the space been mechanically ventillated adequately prior to entry?
6 Has a portable blower been installed to continuously ventilate the space during entry and ensure
air changes?
7 Is a ladder and other means of exit available and secured?
8 Is the cover secured and open?
9 Are all entrants wearing a full body harness with a lifeline attached to an overhead pulley that is
in good condition?
10
Has a watch person (standby) been assigned and given proper instruction and training? Name:
11 Does the standby have a communication method to summon assistance?
12 If welding or cutting, has local exhaust been provided?
13 Do welders have the required respiratory protection?
14 Is appropriate PPE and insulated mats and coverings provided for welding or electrical working
the space?
15 Are all electrical tools and equipment grounded and earthed?
16 Are all gas hoses in good condition and tested for leaks?
17 Are continuous detectors used to monitor oxygen LEL levelsat several locations within the
space? If so has the meter been calibrated?
18 Is the oxygen level between 19.5% and 23.5% ?
19 Is the LEL level at 0 ?
20 Has the work been stopped and space investigated if oxygen and LEL levels are outside the
specified parameters ?
21
Are there any electrical hazards ?
22 Noise / heat / adjacent work ?
23 Is the equipment drained, gas freed, flushed and blinded / isolated from other systems
mechanically?
24 Has the vessel been thoroughly cleaned and purged ?
29 Are all hand tools to be used in order?
30 Have the workers been informed about the emrgency procedure?
Warning: Smoking / Tobacco in the premises is strictly prohibited.
31 Are all temporary electrical connections give safe and have been done by using proper lugs,
plugs and sockets and connections tightened?
32 Is it required to impair the Fire Alarm system? If so follow the imparment program.
Particulars of the work crew
Name Signature Name Signature
Certificate by the Vendor/Vendor's supervisor Certificate by the KF Shift engineer/Asst. FM
I have checked the area and have thoroughly checked the points I have checked the area and have thoroughly checked the points given
given in the checklist above.I have instructed my work crew on in the checklist above.I have verified that the work crew are aware of
how to carry out the job safely.I will ensure that the safety how to carry out the job safely and how to use the safety equipment.
instructions are followed throughout the execution of the job. The job can be carried out safely and Work permit can be issued.
Signature Time: Signature Time: Signature
Date: Date: Date:
Certificate by the Authority issuing the work permit
Certifiied that I have personally checked the area, the safety and the equipment and consider it safe to carry out the work. If at any stage it
is found that the safety measures are being violated the work will be suspended with immediate effect.
Signature of person issuing the permit.
Date: Time:
Time Work completed:
All the tools have been removed from the place of work.
The area is clean and cleared of all material, waste / dirt.
Work has been completed safely and there is no injury to any person and no damage to any equipment/material.
Signature Signature Signature
(Vendor) (KF Shift engineer/Asst. FM) (Issuing authority)
Procedure for issuing Work permit
1 This work permit is required for all jobs where there is entry into confined space such as tanks, pit etc.except involving hot inside
confined space in which case a separate work permit is required with additional precautionary measures.
2 The work permit should be made in duplicate. One copy will be given to the supervisor undertaking the job and will be retained by
him at site during the execution of the job. The second copy will be retained by the issuing authority.
3 The Facility Manager is authorised to issue the work permit.
4 The work permit will be filled by the vendor carrying our the job, reviewed by the KF shift engineer/ Asst. FM and then Facility
Manager will verify all the points and then issue the work permit.
5 Work permit will be issued for one day. It will be reviewed/revalidated when the shift is changing. A fresh work permit will be issued if
the work is to be continued on the next day.
6 After completion of work the permit will closed and submitted to the issuing authority before leaving the site.
7 LPG cylinders are not permitted for gas cutting operation.
Warning: Smoking / Tobacco in the premises is strictly prohibited.
