Work Permit Review Sheet

FIRE PROTECTION Yes No N/A Comments

1. Fire Protection Equipment Adequate
2. Fire Watch Available / Knowledgeable
3. Sewers Covered Within 75 feet of Hot Work
Permit Type Hot ( ) Cold ( ) Entry ( ) Release ( )
Permit Number: Date:
Issuer Organization: Duration:
Receiver Organization: Issuer No.
Work Location: Receiver No.
Work Description:

DOCUMENT REVIEW Yes No N/A Comments

1. Correct Type of Permit
2. Issuers Certification is Current
3. Joint Site Inspection Conducted
4. Permit Properly Countersigned
5. Proper Gas Tests Recorded
6. Permit Properly Closed Out/ Extended
7. Gas Test Equipment Operational

GENERAL Yes No N/A Comments

1. Permit Available at Site
2. Receiver / Delegate Available
3. Receiver Certification Current
4. Work Slope Properly Defined
5. Equipment Properly Identified
6. Hazards Properly Identified
7. Precautions Properly Identified
8. Gas Test Properly Conducted
9. Receiver Following Permit Instructions

SITE CONDITIONS Yes No N/A Comments

1. Barricades/Warning Signs Adequate
2. Personal Protective Equipment Adequate
3. Issuers Lock and Hold Tag Adequate
4. Receivers Lock and Hold Tag Adequate
5. Stand By Man Available
6. Tools in Acceptable Condition
7. Scaffolding Acceptable
8. Acceptable Excavation Procedures Followed
9. Equipment Isolated and Pressurized
10. Equipment Cleaned and Purged
11. Crane Inspection Sticker Current
12. Housekeeping Acceptable
13. Health Hazards Addressed

FIRE PROTECTION Yes No N/A Comments

 1. Fire Protection Equipment Adequate
2. Fire Watch Available / Knowledgeable
3. Sewers Covered Within 75 feet of Hot Work

OTHER COMMENTS
1.
2.
3.
Reviewer’s Reviewer’s
Name:___________________ Signature: ______________ Date: ___________ Time: __________