Request for a HOT WORK PERMIT from Estates Services

1 Staff name: (requesting permit) ………………………………………..………………….....…………………..

1 Contractor name: …………………………………………………………………………………..……………..

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2 Name of person undertaking the Hot Work: ………….…..………………………………………….………

1 Work activity: …………..………………………………………………….……………………………………….

………………………………………………………………………………………………………………………...

Location: …………………………………………………………………………………………………………...

Date and anticipated duration Hot Work Permit is required: ……………...………………………..…….

Please confirm by way of ticking the boxes and signing below that the following is in place;

¨ The organisation is Approved by the Faculty / Service for undertaking such works.

¨ The organisation has suitable Public Liability insurance cover in place.

¨ The individual tasked to receive the Permit is considered competent by the Faculty /
Service.

¨ The wider work activity will be managed by the Faculty / Service.

¨ Suitable Risk Assessments are in place for this activity and will be within the possession
of the person undertaking the Hot Work.

¨ The contractor has been made aware of local hazards in the area of work.

¨ Consideration for segregating the works from students / staff has been undertaken.

¨ Persons likely to be affected by these works have been prior notified of the impending
Hot Works.

I the undersigned can confirm that the above checks have been undertaken.

Facilities Directorate Health and Safety Management

Document No. Rev Date Section title Section 4.6 D

4.6 D5 01 03-14 Request for a hot works permit Page 1 of 2

Signed: ……….……………………………. Date: ……….…………………………….

Position: ……….……………………………. Tel. no: ……….…………………………….

This form MUST be countersigned by Health & Safety Co-ordinator / Health Safety
Manager prior to submission.

Signed: ……….……………………………. Date: ……….…………………………….

Please report /forward the completed form to Estates Helpdesk eshelp@leeds.ac.uk.

Where feasible please allow 48 hours notice.

Facilities Directorate Health and Safety Management

Document No. Rev Date Section title Section 4.6 D

4.6 D5 01 03-14 Request for a hot works permit Page 2 of 2