PERMIT TO OPEN BARRICADES / GUARDRAILS / FLOOR OPENING COVERS

Project: Permit No:

Details of barricades / guardrail / floor opening to be opened
(To be filled by the person requesting permit)
Company / Contractor: Number of labourers deployed for the job:
Location:
Date: Time: From ____ am/pm to ____ am/pm
Name of work engineer: Mobile No:
Name of site supervisor: Mobile No:
Purpose:

Safety Precautions
(To be inspected and filled by the person requesting permit - H&S representative to verify)
Sl No Safety Check Points Yes No Comments
1 Approved RAMS available for the job to be carried out
2 The workers briefed about all risks and risk controls
3 All workers are provided with helmet and safety shoes
4 Sufficient safety harnesses is provided
5 Adequate illumination provided
6 Area is fenced to prevent unauthorised entry
7 Display of warning signs sufficient
8 Emergency contact numbers displayed
9 Provision of temporary barricades during tea / lunch breaks
Permit request by the work engineer & Supervisor
I have inspected the above points and found them to be complied with. I find it safe to remove the
barricades / guardrails / floor opening covers for the specified purpose / job.
Name of the work supervisor: Signature: …………………… Date: ……………………

Name of the work engineer: Signature: …………………… Date: ……………………

Verification by the contractor's H&S representative
I have inspected and verified the safety arrangements in the stated location. I find it satisfactory to
permit the works.
Name of the H&S representative: Signature: …………………… Date: ……………………
Authorisation

I have cross-checked and found to comply with the safety precautions.

Specific H&S remarks for to be taken care during / after the job:

………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………

Name of the issuing authority: ……………………………………………… Signature: ………………… Date: ……………………

Permit Closure
The floor edge / floor periphery has been barricaded / covered adequately
Name of the work supervisor: ………………………………………………… Signature: ………………… Date: ……………………
Name of the work engineer: …………………………………………………… Signature: ………………… Date: ……………………
SD04 v1706