a):b):c):d)From:To:e)Barricades/ Warning SignsSafety Harness with lifelineNon-sparking ToolsDust MasksHard HatMarshal/ Stand by manAccess LaddersOthers (Please Specify)(Please tick where appropriate)f)Name of Competent Person:Safety Assessorg)No. of Workers:h)Name::Date :
Demolition Work/ Working at Height(More than 2m) Permit-To-Work
Permit-To-Work to be displayed at work area(Delete where not applicable)
Location of WorkDescription of WorkDate/s of WorkI wish to carry out the above work, I undertake to comply with the requirement stated above andmaintain them throughout the work.I have read and understood the Permit-To-Work and shall comply with General Safety Procedure.Time of WorkThe following safety equipment/special provisions must be provided and maintained throughout thework.