(A) Work Permit No.

:-   Date:____________
Person In Charge of the Work:__________________________________________________ Position:__________________

Location of Work:_____________________________________________________________

Name of the Contractor:________________________________________________________  

Department of Doing work:__________________________________________________________

PLAN

Brief Description of Work:___________________________________________________________________________________

Number of persons working:______ (List of persons to be attached)  
(Permit is valid for only one
Issue time:____________ shift)  
Ye
Will Hot Work be conducted? s No (Tick)  
If answer is Yes, a Hot Work Permit must be completed Hot Work Permit No:_________________
 
 

(B Ye N N/ Ye N N/ Ye N N/
) General s o A   s o A PPE s o A
Scaffold Checked and Mandatory PPE
Working area free from Overhead Power
Certified
lines       Hard Hat      
if yes, Name & Designation
of
Scaffolder:______________
Sufficient Illumination provided       _____       Safety Shoes      
INSPECT

Proper means of Access through ladders Scaffold been tagged Reflective

(Aluminium ladders/staircase) "Green"(Safe to use)       Jacket      
      Double
Lanyard
Working platform closely safety
      boarded       harness      
Ladders secured       Sole Plate, Base plate       Hand gloves      
Working platform free from      
Ladders placed at right slope (less than or
hazards such as slip, trip,
equal to 750)
      trap       Optional PPE
 Man baskets used are
Life line provided       Certified       Fall arrestors      
Area below work is barricaded       Working platforms with Toe Ear plugs      
Safety Net for man & material (if height is board, mid rail, Guard rail       Nose mask      
more than 6 meters)       Goggles      
Wheel lock is provided
Condition of weather       (*Mobile Scaffold)              
Is Condition of bracings
Base away from all excavations, drain covers, good?              
manholes etc., Scaffolding Structure
      Securely tied back              
Scaffold erected on firm
workers with ID Cards       ground            

Other Measures:-
______________________________________________________________________________________________________________________
   
Ye
(C) s
No

Has the SOP communicated to each person who will be performing this work through PRE-TASK BRIEFING?    
COMMUNICATE

Does everyone understand the plan, their part in the plan and the controls required?    
Have all persons who may be affected by this work been adequately informed of the consequences and the control
   
measures required?
Is it safe to proceed?    
 
 

(D
NO WORK TO BE CARRIED OUT UNDER THIS PERMIT UNTIL ALL THE ITEMS UNDER SECTION (B) & (C) HAVE
) FULFILLED
CONTRO

 
I confirm that I have been given charge of the above mentioned work and I will take all necessary precautions to avoid danger to the
 workers engaged at the work as well as property. I will abide by the recommendations of the Safety Representative and implement
them and I will assign jobs to only trained personnel. I assure that Buddy system is followed during work.

Name & signature of the Engineer / Date:______

Supervisor:___________________________________________________________ _ Time:____
Date:______
L

Name & signature of the Person In charge / Authorised Person:_____________________________ __ Time:____

Handover the Signed Permit to :-_________________________________ (SHE Department)  
Reason for Permit Date:______
Suspension:_________________________________________________________________ _ Time:____
Date:______
Suspended by:____________________________________________________________________ _ Time:____
   
Work is completed and is in safe condition. Tools / Materials / Equipments have been removed and the area is clean and orderly.
CLEARANCE / CANCELLATION

Head Count has been done.  

 
Work completed (Including Housekeeping) Time:_______ Date:__________  
Name & signature of the Person In charge / Authorised Person:_______________________ Time:________ Date:____
 
"RETURN THIS PERMIT WHEN WORK IS COMPLETED OR AT THE END OF SHIFT"