THE PROVISION OF PIPELINE INSTALLATION

SERVICES

SMG1 FLOWLINE PROJECT

ELECTRICAL WORK PERMIT

Document N° : Contract N° : Page 1 sur 2
……………………… …………………….……………………………………

ELECTRICAL
WORK
PERMIT
Permit No.

Details of Work:
Location of Work:

Description of Hazards:

Expected Work Period: From hrs. To hrs. Date:

Other Permit Required:

Task Supervisor Name: OWNER: Signature:

No. of Workers:

Equipment & Tools to be used:

Safety Checks N / A : Not Applicable

Item YES NO Comments

A. Work Requiring Isolation

Isolation plan provided

Approved Work Method Statement Provided

All switch boxes double locked up Caution signs tagged

Warning notices provided At prominent locations

Work area fenced or roped off or screened

Apparatus dead proved by test To be confirmed by test

Earthing provided

Other necessary precautions

B. Work on Live Equipment

Approved Work Method Statement provided

Safety equipment provided

- Insulating rubber gloves

- Insulating rubber boots

- Insulating rubber mats

- Other tools and equipment

Danger & caution notice posted& Access Controlled

Safety Training Provided

Other necessary precautions

Special Note:
Any Electrical work that requires isolation shall have a Checklist for the Electrical Isolation Certificate (SF016) and shall
be duly signed and witnessed by the Contractor Electrical Engineer responsible for the work.

Work Permit No.:

Validity of Permission From hrs.To hrs. Date:

Reviewed by : Name & Title: Signature:

Issued by: Name & Title: Signature:

Received by: Name & Title: Signature:

Revalidation Permit:

Revalidated DATE

TIME

Issuer NAME

SIGNATURE

Permit closure:

Closed by (Receiver) Name: Time closed: Signature:

(Issuer) Name: Time closed: Signature:

Performing authority Issuing Authority Area Authority