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WORKSITE:
DATE: DATE:
TIME: TIME:
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SIGNATURES IN CORRECT SEQUENCE: (All signatories in this certificate shall be aware of the responsibilities laid down in this permit.)
CONTRACTOR SAFETY OFFICER PROJECT IN-CHARGE FIRE LIFE SAFETY MANAGER DIRECTOR OF ENGINEERING
I confirm that the safety precautions As project lead, I have coordinated I have checked & certified that all I am aware of the job to be done and
specified will be observed. with area in-charge & security for any precautions established are and the precautions to be taken.
operational requirements. adequate.