PERMIT TO COMMENCE WORK

1. DESCRIPTION Ref No: Date of application:

SCOPE OF WORK LOCATION OF WORK
2. HAZARD ASSESSMENT (people, property, e!"ro#et$
ASBESTOS
CONFINED SPACE
CORROSIVE SUBSTANCE
DUST
ELECTRICITY INC. STATIC
FIRE & EPLOSION
FLOODIN!
!AS " FU#ES
$OT SURFACES
$YDRAULIC PRESSURE
IN %ALL SERVICES
LONE %OR&ER
#ANUAL $ANDLIN!
%ASTE DISPOSAL"SPILLS
#OVIN! #AC$INERY
NOISE
OVER$EAD $A'ARDS
PRESSURE"VACUU#
RESTRICTED ACCESS
C$E#ICAL USE
$A'ARDOUS SUBSTANCES
TRAPPED $EATIN!
TRAFFIC"VE$ICLES"PEOPLE
UNDER!ROUND SERVICES
UNEVEN"SLIPPERY SURFACES
%OR&IN! AT $EI!$T ().*+
%OR& OVER"NEAR %ATER
OT$ER ,,,,,,,,.,
RISK ASSESSMENT COMPLETED
%e& No
'o( S)*ety A)ly&"& +o#plete,
%e& No
-Copie. to /e .i01te2 an2 3etaine2 /4 Facilit4 #ana0e35
Are )ll +-e#"+)l& )ppro!e,.
%e& No
RISK TO EN/IRONMENT0PROPERT%
1. CONTROLS 0 PRECA2TIONS
F2RTHER PERMITS
CONFINED SPACE PER#IT No. ..............
$OT %OR& PER#IT No. ..............
$I!$ VOLTA!E"LIVE PER#IT No. ..............
OT$ER ..........................,,... No. ..............
WORK PRACTICES
PERSONNEL INDUCTED
TRAININ! VERIFIED
DIRECT SUPERVISION RE6UIRED %ES NO
OT$ER:
PERSONAL PROTECTI/E E32IPMENT RE32IRED
Safet4 !la..e. Face S1iel2 $ea2 S1iel2 !lo7e.
$a32 $at Safet4 Foot8ea3 !a9ntlet.
$ea3in0 P3otection P3otecti7e Clot1in0 Safet4 $a3ne..
EN4INEERIN4 -e0. Ba33ie3.: Scaffol2in05
%o3; 8ill /e con29cte2 in a $V A3ea -/9t not on $V e<9ip+ent5 & t1e .afet4
3e<9i3e+ent. 1a7e /een e=plaine2 an2 a3e f9ll4 9n2e3.tan2 /4 all.
%ES NO
PRECA2TIONS TO 5E TAKEN
6. ISOLATION 7 Lo+8o9t : T);o9t Pro+e,9re (t-"& "+l9,e& ere+t"o o* ()rr"er& : &";& )& )ppropr")te$.
TA4 0 LOCK No<&. NAMES TA4 0 LOCK No<&. NAMES
=. PERSONNEL ASSI4NED
PRINT NA#E SI!NATURE PRINT NA#E SI!NATURE
1. 6.
2. =.
1. >.
>. WORK CLEARANCE %e 1a7e 2i.c9..e2 t1e potential 1a>a32.: i2entifie2 t1e app3op3iate cont3ol. an2 p3eca9tion. fo3 t1e ta.; an2 en.93e2 t1at t1e.e
1a7e /een a223e..e2.
N)#e Signature Responsible Date
CONTRACTOR
A B
DEPARTMENT MANA4ER
A B
DCT MANA4ER
A B
FACILIT% MANA4ER
A B
A ? #ain Spon.o3 B ? Co@Si0ne3
>. /ALIDIT%:
/ALID FROM (T"#e$ /ALID TO (T"#e$
?. WORK COMPLETION (To (e &";e, o** o +o#plet"o o* t)&8 or )t e, o* !)l","ty per"o,$
Ta.; Co+plete2 & A..et Ret93ne2 to Safe Con2ition
Ta.; Inco+plete. Ao/ Site left in Safe Con2ition
Co+pletion of Ta.; Ve3ifie2 & A..et Fit fo3 Ope3ation
Ca334@o7e3 of Ta.; App3o7e2 & Safe Con2ition of Ao/ Site Ve3ifie2
M)" Spo&or @ CoAS";er @ Cotr)+tor0 Co#p)y @ D)te : T"#e @
FOR#: LOP).).* DOC@BB) Re7B)