WORK PERMIT FORM

THIS PERMIT WILL BE FORWARDED TO SECURITY PRIOR TO START OF WORK:

AREA/DEPARTMENT: DATE APPLIED:

CONTRACTOR: ESTIMATED DURATION:

WORKSITE:

CONTRACTOR SUPERVISOR: DESIGNATION:

JOB TO BE DONE: WORKPLACE SAFETY PRECAUTIONS/

PERSONAL PROTECTIVE EQUIPMENT
fire extinguisher Noisy Work Permit
standby firehoses/AFF's Hot Work Permit
warning signs /cordons Confined Space Permit
face mask/goggles Electrical Safety Permit
ear muffs/ear plugs Foul smell permit
lighting Working at Height Permit
safety gloves Area-in-charge consent
Safety shoes BESC
helmets / apron
Others

LIST OF TOOLS AND EQUIPMENTS TO BE USED:

VALIDITY : PERIOD VALIDATION
FROM TO

DATE: DATE:
TIME: TIME:

Validity of this permit should not exceed 7 calendar days

PEOPLE ON THE JOB: Please check, if present Please check, if present

Name Date Name Date

1. 7.

2. 8.

3. 9.

4. 10.

5. 11.

6. 12.

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.