Permit to Work Plan

Your Company Name

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Contents
ACRONYM LIST....................................................................................................................................................5
1. SCOPE............................................................................................................................................................6
2. OBJECTIVES.................................................................................................................................................6
3. DEFINITIONS, TERMS, AND ABBREVIATIONS.......................................................................................6
4. RESPONSIBILITIES.....................................................................................................................................7
4.1 YOUR COMPANY NAME Site Manager..............................................................................................7
4.2 YOUR COMPANY NAME Construction Manager.............................................................................7
4.3 YOUR COMPANY NAME Field HSE Coordinator (FHSEC) on site.................................................8
4.4 YOUR COMPANY NAME PTW Coordinator......................................................................................8
4.5 Subcontractor Construction Manager............................................................................................8
4.6 Subcontractor HSE Manager.............................................................................................................8
4.7 Employees............................................................................................................................................9
5. PERMIT TO WORK SYSTEM WORKFLOW...............................................................................................9
5.1 Workflow Description.......................................................................................................................9
5.2 Subcontractor Receiving Authority (Originator).......................................................................10
5.3 YOUR COMPANY NAME Permit to Work Coordination Meeting...............................................10
5.4 Contractor Issuing Authority (Validator)....................................................................................10
5.5 Contractor Permit Coordinator.....................................................................................................11
5.6 Contractor Operating Authority (Operator)..............................................................................11
5.7 Subcontractor Performing Authority (Performer)..................................................................12
5.8 Minimum Acceptance for Permit Signatories.............................................................................12
6. TYPES OF PERMIT....................................................................................................................................13
6.1 General...............................................................................................................................................13
6.2 Activities Requiring a Permit to Work.........................................................................................14
6.3 General Work Permit (cold)...........................................................................................................14
6.4 Hot Work Permit..............................................................................................................................14
6.5 Radiography Work Permit..............................................................................................................14
6.6 Other Permits and Certificates......................................................................................................15
6.6.1 Confined Space Certificate..........................................................................................................15

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 6.6.2 Electrical Work Certificate.........................................................................................................15
6.6.3 Lock out-tag out............................................................................................................................15
6.6.4 Execution of Energization, Removal of Tags, Padlock and Restoration of Power............17
6.6.5 Excavation Work Certificate.......................................................................................................18
6.6.6 Accompanying Certification for Permit to Work....................................................................18
6.7 Permit issuance and duration........................................................................................................18
6.8 Permit closure...................................................................................................................................20
6.9 Layout and Color of Permits...........................................................................................................20
6.10 Permit and Certificate validity and endorsement periods...................................................20
6.11 Permit to Work Procedure Auditing and Review...................................................................20
6.12 Emergency Response...................................................................................................................21
Attachment 1. Your Company Name Work Permit Forms............................................................................22
Attachment 2. Your Company Name Hot Work Permit Form......................................................................23
Attachment 3. Your Company Name Confined Space Work Permit Form....................................................24
Attachment 4. Your Company Name Confined Space Work Permit..............................................................25
Attachment 5. Your Company Name Daily Permit to Work Review..............................................................26
Attachment 6. Your Company Name Excavation Work Permit.....................................................................27
Attachment 7. Your Company Name Authorization Signatures....................................................................28
Attachment 8. Your Company Name Radiography Work Permit .................................................................29
Attachment 9. Your Company Name Electrical Work Permit .......................................................................30

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ACRONYM LIST
DFW…………………………….Definable Features of Work
FHSEC........................... Field HSE Coordinator
HSE............................... Health, Safety, and Environment
HSE............................... Health, Safety, and Environment
PTW…........................... Permit to Work

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1. SCOPE
Under this contract, YOUR COMPANY NAME will be responsible for the construction of (Project Name)
which will include the construction of (Description of Project) for YOUR COMPANY NAME.

2. OBJECTIVES
The Work Site Safety Plan is designed to give direction and guidance in term of Health/Safety/Environmental (HSE)
requirements to YOUR COMPANY NAME and subcontractor personnel during the construction activities. This
document combined with the HSE Plan for Construction complete the HSE control and management of industrial
and occupational HSE risks during Construction phases. In order to seamlessly adhere to the scope of a project;
plans, policies and procedures shall be modified as required prior to commencement of said definable feature of
work.

The purpose of this document is to enhance management control over the various work activities carried out by
the Contractor and subcontractors, which may be potentially hazardous, within the designated areas known as
Construction Areas. All activities shall also be controlled by a Method Statement. Work shall be performed in
compliance with:
 Federal Regulations
 MSHA
 National Electric Code (NEC)
 National Fire Protection Association (NFPA)
 OSHA 1910
 OSHA 1926
 State Regulations
This procedure defines the administration arrangements of the Permit to Work System only for the
Construction activities phase and must not be used for the Commissioning activities phase, because a
different and specific Permit to Work System will be applied. This work permit procedure will be applied
during the Construction for the work activities carried out in the areas under the direct responsibility and
control of the Contractor.

3. DEFINITIONS, TERMS, AND ABBREVIATIONS

Please refer to the Acronym List after the Table of Contents.

Permit to Work (PTW): Written permission given to carry out work together with any supporting Permits or
Certificate.

Issuing Authority (Validator): The person appointed and authorized by the Contractor and trained to carry out
the task as required by the Permit to Work Procedure, who is responsible for reviewing the submitted Permit,
confirming that the worksite has been examined and all precautions specified to be taken before work
commences have in fact been taken, confirming than no conflict exists with other Permits.

Certificates: Additional form to be issued together with the Permit to Work for the following specific definable
features of work:
 Confined pace
 Electrical work
 Excavation work
 HVAC
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  Plumbing
 Roofing
 Sheet Metal
Receiving Authority (Originator): The person appointed and authorized by the Subcontractor and trained to
carry out the task as required by the Permit to Work Procedure, who applies for a Permit and completes the
Permit for approval by the appropriate Authority, accepting the Permit and agreeing with the Issuing Authority.

Permit Coordinator: Person(s) authorized by the Contractor Construction Manager to issue Permits and trained
to carry out the task as required by the Permit to Work Procedure. This person(s) should coordinate issue of all
Permits to identify potentially conflicting work tasks, both on a geographical and time basis.

User: Person(s)/subcontractor working under an authorized permit.

Employees: All Contractor, subcontractor, vendor and client employees who are included in the organization list
(permanent organization).

Hot Work: Any job within the Contractor area of work, wherein the heat generated is of sufficient magnitude
and intensity to cause ignition of any flammable liquids, gases or any other material. Common sources of ignition
are internal combustion engines, gas cutting torches, welding machines, non-flame proof electrical equipment,
grinders, annealing blankets, jack hammers, etc.

Cold Work: Work which will not involve the use of naked flames nor produce any source of ignition.

Confined Space: Any area that has limited access or egress, or which is sufficiently confined to permit the
accumulation of flammable or toxic gases or vapors, or where an oxygen deficiency or enrichment could
occur.

Electrical Work: A job on any electrical equipment or system.

Excavation and Civil Work: All the excavation jobs.

Radiography Work: A work involving use of radioactive source.

4. RESPONSIBILITIES
4.1 YOUR COMPANY NAME Site Manager
The Site Manager is responsible for all site activities. Appointed personnel will manage most of the aspect of
site activities, including the Permit to Work system and performance. The Site Manager will delegate the duty
of the correct application of YOUR COMPANY NAME Permit to Work Procedure to Construction Manager.

4.2 YOUR COMPANY NAME Construction Manager

The Construction Manager will be responsible for ensuring the effective administration of this procedure
within Construction site activities and shall ensure that this procedure is properly implemented at site. The
Construction Manager shall ensure that all work is carried out under the controls of the Permit to Work System.
Further to this, the Construction Manager shall:
 Provide a safe and healthful environment for all personnel working on the project.
 Ensure that sufficient funds and recourses are made available to ensure the continuity of this procedure for

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 the duration of the works.
 Nominate a Permit Coordinator to ensure that the coordination of permits is administered correctly.
 Ensure the proper coordination of construction activities between YOUR COMPANY NAME and
subcontractors.
 Verify that the subcontractor is providing the correct information and equipment for the scope of work.
 Ensure training is given to all persons requiring how to use a Permit to Work.
 Nominate personnel and authorize them to perform the duties of permit to Work Signatories.
 Approve the personnel nominated by the by subcontractors as signatories of the Permit to Work.

4.3 YOUR COMPANY NAME Field HSE Coordinator (FHSEC) on site

The FHSEC will:
 Perform duties of the position in order to provide a safe and healthful working environment to all
personnel working on the project.
 Ensure that all necessary support, advice and guidance is made available to enable this procedure to be
properly implemented.
 Ensure adequate training to all personnel involved in this procedure.
 Ensure that suitable and sufficient inspections and audits are carried out.
 Evaluate the effectiveness of this procedure and change/amend as is required or becomes necessary to
achieve its purpose.
 Advise the Contractor Management of any irregularities or areas of concern in order to investigate and
to implement corrective actions.
 Maintain a current list of Permit signatories and inform all parties and remove any permit signatory from
the list, found to be in breach of the required duty and responsibility.

4.4 YOUR COMPANY NAME PTW Coordinator

 Assure that all work permit signature flow is in place.
 Verify that the correct work permit is going to be issued for each activity.
 Check that all documentation required as job safety analysis is attached to the work permit.
 Assist FHSEC in all improving activities.
 Stop some work permit if required by FHSEC.

4.5 Subcontractor Construction Manager

Subcontractors Construction Managers will:
 Ensure that sufficient and qualified resources are made available to enable the safe implementation of
this procedure.
 Ensure that all concerned personnel have read and understood this procedure.
 Ensure that adequate facilities and means are in place for the implementation of this procedure.
 Identify and communicate in writing the personnel authorized to sign the work permit such as:
o Receiving Authority and Performing Authority.

4.6 Subcontractor HSE Manager

Subcontractor HSE Manager will:
 Ensure that proper instruction, training and supervision is provided at all times.
 Ensure that suitable and sufficient inspections are carried out by competent personnel, and that
proper records are maintained.
 Ensure that work is carried out in accordance with this procedure.
 Ensure that the conditions are satisfactory for the work to proceed.

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  Ensure that each item on the permit is accurately filled out and covered.
 Ensure that personnel understand the requirements on the permit and any unusual conditions
connected with the job.
 Ensure the continue monitoring of the work area conditions and to stop, the environment and/or
equipment to convey pertinent information about the work to the relievers.
 Advise the Contractor Field HSE Coordinator of any irregularities or areas of concern in order to
identify any necessary corrective action.
 Sign the relevant part of the Permit to Work when applicable.

4.7 Employees
All employees shall comply with the requirements of the Permit to Work Procedure. Any person found to be
in breach of the procedure or deviates from any written instruction shall be subject to disciplinary action,
which may lead to dismissal and action being taken against the individual under the current local Legislation.

5. PERMIT TO WORK SYSTEM WORKFLOW

5.1 Workflow Description
Each permit shall be completed according to the workflow shown in Figure 1, namely by the following steps:
1. The Originator (Subcontractor Receiving Authority) fill in YOUR COMPANY NAME’s PTW proper form(s),
including details showing the equipment, description, location and date and estimated duration of
work;
2. During YOUR COMPANY NAME’s PTW Coordination Meeting, the involved actors analyze the
general permit status, including new permits issue and identify any potential conflicting activities;
3. The authorized Validator (YOUR COMPANY NAME Issuing Authority) check the new permits,
specifying the safety equipment that shall be used and defines any special applicable instruction;
4. The authorized Validator (YOUR COMPANY NAME Issuing Authority) check for existing permits for
revalidation and supervision. If none, issue new PTW.
5. YOUR COMPANY NAME Permit Coordinator distribute copies of new permit to works to the involved parties;
6. Operator (YOUR COMPANY NAME Operating Authority) carrying out all preliminary checks required by
the Validator and will sign the PTW to verify that all requirements have been met and that the work
area is in a safe condition for the work to commence.
7. Performer (Subcontractor Performing Authority) carries out and supervises the works in compliance
with the relevant permit prescription; once completed such activities notify to Validator the permit
closure.

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 Figure 1. Permit to Work System Flowchart
Originator Subcontractor
Receiving Authority
compiles YOUR
COMPANY NAME PTW
Performer Subcontractor
Performing Authority
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Validator
YOUR COMPANY NAME YOUR COMPANY NAME
PTW Coordination Issuing Authority (control,
Meeting validation, and approval)
YOUR COMPANY NAME
Permit Coordinator (Permits
Operator Control Office - HSE Dept.)
YOUR COMPANY NAME
Operating Authority Distribution copies to all
departments
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 In the following paragraphs each step is described in detail.
5.2 Subcontractor Receiving Authority (Originator)
The position of Receiving Authority is the responsibility of the Subcontractor Discipline Engineer who is in
charge of the scope of work to be executed. The Subcontractor Discipline Engineer shall complete the
description of the work to be carried out supplying all relevant information inclusive of drawings method
statements and risk assessments in support of the permit application.

The Subcontractor Receiving Authority of the Work Permit has the following responsibilities:
 To instruct the subcontractor Performing Authority (Performer) of the permit requirements and
satisfy herself/himself that the subcontractors Performing Authority has enough information and
resource to perform the work safely.
 Ensures that the subcontractors Performing Authority understands what, where, and how the work
is to be performed.
 To ensure compliance with the conditions stipulated on the permit.
 To ensure that the Subcontractor Performing Authority supervises the work group and is satisfied
that the persons carrying out the work use the proper tools and equipment for the job.
 That the Subcontractor Performing Authority informs the work group of the safe working practices.
 To inform YOUR COMPANY NAME’s Issuing Authority of any changes in the condition of the job or
the surrounding area, or of any delay in starting the work, so as not to infringe upon any safety
factors.
 Notify YOUR COMPANY NAME’s Issuing Authority upon completion of the work.

5.3 YOUR COMPANY NAME Permit to Work Coordination Meeting

The objectives of this coordination meeting are to:
 Provide the overview of all ongoing and planned work under the control of the Permit to Work System.
 Identify any potential conflicting activities, both geographically (i.e. across other work) or on a time
basis (activities which may start later).
 Agree on requirements of new permits.
 Ensure re-validation of existing permits.

The date, time and place (schedule) of this coordination meeting will be defined at Site by YOUR
COMPANY NAME’s Construction Manager. As minimum the meeting will be attended by YOUR
COMPANY NAME’s Permit Coordinator and appointed YOUR COMPANY NAME and subcontractors
Discipline Superintendent or deputy.

Further attendees, for example technical support, YOUR COMPANY NAME and subcontractors Construction
Manager and/or YOUR COMPANY NAME Field HSE Coordinator, Subcontractor HSE Manager will be present
if requested.

5.4 Contractor Issuing Authority (Validator)

YOUR COMPANY NAME’s Construction Manager shall ensure that there are sufficient signatory’s onsite to
fulfill the role of approving the Permit to Work. This role shall be held by a YOUR COMPANY NAME employee
with the minimum management level of Superintendent and shall sign the Permit to Work as Issuing
Authority. He/She will be the responsibility of the Issuing Authority. No work can commence without the
approving authorities signature.

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 The Contractor Construction Manager may designate persons other than herself/himself to approve
Permits to Work. This designation will be made in writing and informed to the Contractor Field HSE
Coordinator, Contractor Permit Coordinator and all relevant permit signatories.

The Validator of the Permit to Work has the following responsibilities:

 Check the completeness and reliability of the submitted forms.
 Specify the required worksite precautions and controls.
 Detail required safety equipment.
 Identify any worksite preparation requirements, if deemed necessary.
 Ensure that Certificates (attached to Permits as required) for Confined Space work, excavation
and electrical works are duly signed off by authorized engineers.
 Ensure that permits are authorized on the day of use.
 Ensure that permits are closed on the day of use.
No work can commence without the approving authorities signature. In this context YOUR COMPANY
NAME’s Construction Manager or her/his designee has the responsibility of approving the work to
commence and shall sign the Permit to Work as Approving Authority.

5.5 Contractor Permit Coordinator

The Permit Coordinator nominated by YOUR COMPANY NAME’s Construction Manager has the responsibility
of ensuring that all permits to work are entered into the system in the correct manner. Additionally the
Permit Coordinator shall:
 Ensure that all Permits to Work are submitted onetime for entry into the system;
 Ensure that Permit to Work is completed correctly and that all relevant controls and signatures are
added;
 Permit to Work is properly distributed to the interested parties as indicated; understand the scope
and the details of execution of the work;
 Ensure the necessary checks have been satisfactorily executed before signing the permit to work;
 Suspend the Permit to Work at any time if the Permit to Work conditions are not complied with;
 Approve the effective closure of the work and sign for acceptance upon satisfactory completion of
the works.

5.6 Contractor Operating Authority (Operator)

The Operating Authority is responsible for carrying out all preliminary checks required by YOUR
COMPANY NAME’s Issuing Authority and will sign the Permit to Work to verify that all requirements have
been met and that the work area is in a safe condition for the work to commence.

The Operating Authority is nominated by YOUR COMPANY NAME’s Construction Manager.

Additionally the Operating Authority shall:
 Ensure that all signatories have signed the Permit to Work.
 Ensure that all instructions training has been given to the work party prior to the work commencing.
 Inform YOUR COMPANY NAME’s Issuing Authority that he work is about to commence in order
that this can be notified and recorded as a live permit.
 Inspect the worksite periodically to ensure there is no change in condition.
 Suspend the work immediately if there is any breach of this procedure or change in conditions and
to notify YOUR COMPANY NAME’s Issuing Authority for the reason.
 Ensure a good standard of housekeeping is maintained throughout the work and that all equipment
is removed upon completion.
 Notify YOUR COMPANY NAME’s Issuing Authority upon the completion of work; inform YOUR
COMPANY NAME’s Issuing Authority of any change in the working conditions of the surrounding
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 areas in the vicinity of the working area.
Note: it is foreseen that there will be more than one area operator, because as the works progress and as
the work activities increase, then YOUR COMPANY NAME’s Construction Manager may decide to nominate
Operating Authorities by discipline, for example Electrical Operating Authority, Piping Operating Authority,
Mechanical Operating Authority. It may also be possible to divide the site into different areas as the works
again progress so the numbers of controlled areas increase. In this case Operating Authorities will be
nominated for each additional area.

5.7 Subcontractor Performing Authority (Performer)

The Subcontractor Performing Authority is the person responsible for supervising the work group carrying
out the job and shall hold as a minimum the supervisory grade of Foreman. The Subcontractor Performing
Authority is not entitled to start any job without previous approval of the Permit to Work by both YOUR
COMPANY NAME Issuing Authority and Operating Authority. The Subcontractor Performing Authority is
responsible to:
 Ensure the work group carrying out the work is fully briefed usually by means of dedicated tool box
talk.
 Ensure that they have clearly understood instructions given, including the scope of their activity
and the relevant risks.
 Remain at the worksite until the completion of the task.
After signing the Permit to Work the Subcontractor Performing Authority shall ensure that all copies of the
Permit to Work are correctly distributed and that a copy is retained and posted at the work site. In addition
the Subcontractor Performing Authority shall:
 Inform the subcontractor Receiving Authority or Contractor Operating Authority of any change in
the working conditions of the job, or a delay in starting the work.
 Using proper tools and equipment for the safe execution of the job.
 Ensure the worksite is left in a safe and tidy condition.

5.8 Minimum Acceptance for Permit Signatories

The key steps of validating, issuing, accepting and endorsing of Permits is done by person who has been
assessed as competent. Permit signatories are those who have had sufficient training and experience and
have been duly authorized as those Permit signatories by YOUR COMPANY NAME’s Construction Manager
for the Permit Coordinator, Issuing Authority and Operating Authority and by the Subcontractors
Construction Manager for the Receiving Authority and Performing Authority.

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 It is essential for example that a signatory fully understands the requirement. Figure 2 illustrates
the minimum acceptable level for permit to work signatories.

Figure 2. Matrix of Permit to Work Authorization and Receipt for Permits to be Used.

Minimum level for

Issuing (Approving) Minimum level for Minimum level for Performing
Authority Operating Authority Receiving Authority Authority Validity
Issuing (Approving) YOUR COMPANY NAME Subcontractor Subcontractors Validity of the permit to
Authorities shall be Discipline Superintendent Foreman work will be marked
designated by YOUR Supervisor upon the permit and is
COMPANY NAME’s unconditional
Construction Manager

6. TYPES OF PERMIT
6.1 General
A written permit to work system provides formal written procedure and formal actions to ensure that
potentially hazardous activities are carried out as safely as possible. The work permit is a written
document which authorizes persons to carry out the work concerned warns of possible dangers and
clearly states the precautions to be taken for the job to be carried out safely.

The permit ensures that full consideration is given to the hazards and risks, and that these are properly
dealt with, prior to commencement of the work. The permit to work has to be filled by the subcontractors
for what concerns its activities and references. Contractor will give the necessary support as required.

The permit to work shall clearly specify the particular equipment and the construction area involved,
the extent of work allowed, the conditions to be observed and the duration of the permit. Should any
doubt exist as to the requirements for specific types of Permits, YOUR COMPANY NAME’s Field HSE
Coordinator and/or YOUR COMPANY NAME’s Permit Coordinator should be consulted for advice.

The instructions in the procedure are the minimum requirement and are mandatory. Personnel must at
all times comply with them and are not permitted to make arbitrary changes. The present procedure
considers the following permits and certificates:
 General Work Permit (cold)
 Hot Work Permit
 Radiography Work Permit
 Confined Space Certificate
 Electrical Work Certificate
 Excavation Work Certificate
Note: Confined Space, Electrical and Excavation Work Certificate, signed by authorized engineers, must
always be combined with General Work Permit (cold) or Hot Work Permit.

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6.2 Activities Requiring a Permit to Work
A Permit to Work will be required for the following activities:
 Any activity on live electrical equipment.
 Areas electrically classified.
 Closure of site roads to enable excavation and similar activities to be carried out.
 Confined space work (i.e. any work inside a vessel).
 Confined space work.
 Connection to the electrical supply.
 Connection to the water supply.
 Crane Lifts; lifting operations over living lines / equipment.
 Disconnecting or opening of any closed pipeline or vessel containing flammable or other hazardous
material.
 Erection of site huts and lay down areas.
 Excavation and trenching.
 Facilities for the storage of cylinder gases, highly flammable liquids, paint or similar hazardous
materials.
 Hot work of any type, where heat is used or generated.
 Hot work.
 Installation of pits for the storage of sealed radioactive sources.
 Isolation/lock-out/tag-out.
 Radiography (i.e. any work involving use of radioactive source, including the installation of pits for
the storage of sealed radioactive sources).
 Working in hazardous zoned areas.

6.3 General Work Permit (cold)

 The general Work Permit shall be utilized for all activities requiring a Permit to Work, other than
those capable of generating or using sources of ignition.
 The general Work Permit will facilitate all activities from scaffold erection to those controlling
activities such as pressure testing.
 The general Work Permit has the facility to be validated for a period of 28 consecutive days.
 Revalidation of any Permit to Work shall remain at the discretion of YOUR COMPANY NAME’s
Construction Manager and only if all Permit Signatories are in agreement, that there is no significant
change in condition, changes in work schedule or there is no significant changes in personnel.
 Permits to Work shall clearly specify the particular equipment and the construction area involved
the extent of work allowed, the conditions to be observed and the duration of the permit.

6.4 Hot Work Permit

The Hot Work Permit shall be utilized for all activities requiring a Permit to Work, capable of generating or
using sources of ignition.

6.5 Radiography Work Permit

 The Radiography Work Permit is to control all site radiography and the use of ionizing Radiation. It
is imperative that the controls remain in compliance with government legislation regulating the
movement and uses of radioactive sources.
 The Permit should be used in conjunction and in agreement made between YOUR COMPANY NAME’s
Field HSE Coordinator, YOUR COMPANY NAME’s Permit Coordinator and the Subcontractor RPS
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 (Radiation Protection Supervisor) to ensure provision is made for the inclusion of local rules
requirements to be submitted with the permit to work.
 The subcontractor should stipulate the type of source to be used, the ID number of the source, and
the records and timings of source movement from storage facility to the work area.
 Prior to the signing of the Permit to Work the subcontractor shall demonstrate that the area is
completely fenced by means of warning tapes and signoff and that there is no risk to personnel from
the use of radioactive substances.
 An RPS nominated by the subcontractor shall be present at site during site radiography to oversee
all activities and to sign relevant documentation.
 The RPS shall remain at the worksite for the duration of radiography work.

6.6 Other Permits and Certificates

Should additional and/or other permits be required, they shall be created prior to commencement of work on
definable features of work.

The following Certificates shall be issued with the Work Permit (both general and hot) and they give details
of the existing situation of the area.

6.6.1 Confined Space Certificate

 The Confined Space Certificate, shall be used in conjunction with the Permit to Work (both general
and hot), and is required for any entry into a confined space as defined in this section.
 The Confined Space Certificate, once in place, only controls the entry of persons into a confined
space. The actual task shall be controlled by the general Permit to Work. The Permit numbers shall
be cross referenced to each other.
 Entry into confined spaces is subject to special requirements being put into place prior to the
commencement of work. This will include but not be limited to:
o Condition monitoring
o Presence of a Safety Watch Person
o PPE/RPE
o Emergency Escape Plan

6.6.2 Electrical Work Certificate

This Certificate shall be used in conjunction with the Permit to Work (both general and hot), for any
activity to be carried out on live electrical equipment or plant.

The Electrical Competent Person should complete this form and demonstrate that all necessary isolations
have been made and that the system or plant is safe to be worked on.

The electrical work certificate shall be utilized when an energization or de-energization operation should be
carried out.

6.6.3 Lock out-tag out

De-energization (Isolation) may be required prior to installation, inspection, repair, cleaning or
dismantling. Where a job involves isolation of equipment, there shall be a work permit for the job and
a lockout and tag-out procedure shall be followed.

A lockout generally involves:

 Stopping all energy flows (for example, by tuning off switches or valves on supply lines).

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  Locking switches and valves.
 Securing the machine, device or power transmission line in de-energizer state.
Electrical isolation may be required to immobilize machinery or to protect personnel working in electrical
equipment. Situations involving electrical isolation including rotating machinery and machinery with moving
parts and entry into vessel which contain stirrers or agitators. Electrical isolation should be performed only
by a competent electrical engineer.

Energization may be required for executing pre-commissioning electrical test. Where a job involves
temporary energization, there should always be a work permit for the job and a power on and power off
procedure should be followed.
 The padlock has to be provided with a tag reporting:
 ID number as recorded in the isolation log book.
 Date and time of lock out.
 Name and signature of the individual who installed the padlock and the reason of the installation.
 Warning tags has to be properly secured with wire to the isolation points to ensure the same does
not fall off.
An example of a Warning Tag and Tag-out and lock-out are shown in Figure 3.

Figure 3. Example Warning Tag and Tag-out/Lock-out tags.

TAG No.

DO NOT
OPERATE

CAUTION

REMARKS :

DATE :

SIGNED BY :

COMMISSIONING TEAM

If the equipment is provided with an electrical isolation facility available on the field (e.g. start/stop button
or other switchgear) then the Competent Electrical Engineer should attempt electrical start test in the
field. This is to ensure that the equipment is no longer live and to verify that the electrical isolation is
effective. The Competent Electrical Engineer then, shall fit a second numbered padlock, together with a
“Danger: Do Not Operate” tag, to the local electrical isolation point.

In situation where it is not possible to lockout or chain off an isolating device, isolation may be accomplished
by removal of fuses, disconnection of electrical cables or physical removal of a component of the system
supplying energy to the equipment. The point of physical interruption shall be identified with a dedicated
tag.

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 If other organizations or individuals working on equipment shall also install their locks and tags at locations
have to be fit. In that case multiply lockout clips (Hasps) shall be used if necessary. When all padlocks will be
removed energization will be possible. An example of Hasps is shown in Figure 4.

Figure 4. Example HASP

The Competent Electrical Engineer shall report all actions on the substation logbook for record purpose. As a
general rule other discipline engineers cannot interfere with any electrical isolation work to be executed
inside the substation for safety reasons and nobody (with the only exception of the Competent Electrical
Engineer) can take or keep the padlock keys for their scopes.

Field HSE Coordinator should hold spare keys for all Lock Outs. This ensures no keys will go missing, if they
are controlled by the Permit to Work Coordinator.

6.6.4 Execution of Energization, Removal of Tags, Padlock and Restoration of Power

After receiving the Electrical Certification in which the ENERGIZATION is required the Competent
Electrical Engineer shall proceed to energize the equipment. The following procedure covers the
energization for safe execution of the pre-commissioning electrical tests.
 If a padlock and a tag are installed (to show that the switchgear is isolated) the Competent Electrical
o Engineer shall remove both of them.
 The Competent Electrical Engineer will give power to the equipment.
 As soon as the equipment is energized the Component Electrical Engineer shall hung a tag “IN
SERVICE” close to the switchgear, as shown in Figure 5.

The Competent Electrical Engineer shall report all actions on the substation logbook for record purpose.

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 Figure 5. Example of “In Service” tag.

6.6.5 Excavation Work Certificate

This Certificate shall be used in conjunction with the Permit to Work, for Excavation activities. This
Certificate should be submitted with the Permit to Work together with any supporting documentation such
as sketches drawings and method statements. In this shall be reported all the underground services present
in the area.

6.6.6 Accompanying Certification for Permit to Work

The more information there is to support a permit to work, the more safety factors can be considered or put
in place to make the job safer. Therefore it is important to submit supporting documents in the form of site
layout drawings, equipment drawings, etc. with the certificate. This is especially important when trying to
locate underground services and etc. Failure to provide these documents may result in an application being
rejected.

6.7 Permit issuance and duration

The Permit to Work will involve the following steps shown below:
1. Conduct a thorough risk assessment and determine who is at risk, what control measures are necessary
to eliminate the hazards, and the level of residual risk.

2. Prepare a written system of work identifying the following:

 The level of competence of all operatives and any specialist skills
 List Isolation / Pre-work precautions
 List prohibited activities (communicate to others as necessary)
 List Plant and Equipment required
 List Personnel Protective Equipment to be used
 List sequence of events as planned with identified hazards/residual risks and controls clearly
defined
 Emergency procedures for all foreseeable risks (ensure that procedures are conveyed to
competent persons and fully understood)
3. Brief those who will be required to operate under the Permit to Work on the hazards and controls
necessary to avoid them being realized (for example during Tool Box Talks).
4. Ensure that those conducting the task know that the safe system must be followed in full and that no
other methods or sequence of work are allowed (i.e., work must stop, all persons withdrawn, and the

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 safe system reviewed by the Authorized Person). If the safe system is found to be flawed, then the
Permit must be cancelled, the system of work reassessed, a new Permit raised, and those conducting
the task re-briefed.
5. Display the Permit at the work site/isolation point to ensure all that those who need to know, do so.
6. Ensure that the work area is clean, tidy, and that all safety devices have been replaced and are
functioning correctly, prior to inspection by the Authorized Person. Please note the
Authorized Person must not sign the “hand back” section of the form until the area is in fact
clean and safe.

Any person requiring permit to work must submit their request to Contractor Permit Coordinator at least
one working day prior to the commencement of the work. Prior to issuing the permit, the Contractor Permit
Coordinator should satisfy himself that the safety conditions described in the permit are correctly applied.

If any conditions required by the work permit cannot be met, the permit is to be withdrawn by the
Contractor Construction Manager or the Area Superintendent and the work must not be allowed, until
remedial actions have been taken.

If the work extends beyond the stated validity period, then the permit is to be returned to the Contractor
Construction Manager or the Area Superintendent and the work suspended until the extension has been
authorized.

The requirement for a Permit to Work inside the Contractor controlled area will remain at the discretion of
the Contractor Construction Manager. However certain activities may be necessitated without the need for
a Permit. More specifically, these works may include:
 Maintenance and repair, of subcontractor’s plant.
 Inspection activities, excluding Vessel Entry.
 Testing of plant & equipment, excluding pressure test and weight test.
 Alteration, refueling and oiling activities.
 Storage of materials.
 Clean-up operations (excluding the use of Hazardous Substances).
 Work required to create a safe condition.

The Permit to Work can be invalidated under any of the following conditions:
 Two hours or more pass between the preliminary tests and the start of the work (the maximum
acceptable delay shall be anyway evaluated based on the specific conditions).
 For gas testing in confined spaces, the maximum time between the gas test and the entry / work
commencement exceeds 30 minutes (the maximum acceptable delay shall be anyway evaluated
based on the specific conditions).
 The conditions on the permit are not complied with.
 Area or unit conditions change, e.g. venting or spillages of hazardous materials occurred, etc.
 Plant fire & gas/emergency alarm is released.
 Work is carried over to the next shift; in this case the Permit to Work can be renewed; the renewal
shall be done before the next shift is starting its activity.

The validity of the Permit to Work will be evaluated according to the activity and operative patterns, shall be
evaluated at Site by YOUR COMPANY NAME’s Construction Manager (refer to Figure 6).

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 Figure 6 Permit Validity Period
DOCUMENT VALIDITY PERIODS ENDORSEMENT PERIODS
Work Permit (cold) 28 consecutive (calendar) days 7 Days
Hot Work Permit 14 consecutive (calendar) days 12 hours
Confined Space Certificate * 28 consecutive (calendar) days 12 hours
Excavation Work Certificate * 28 consecutive (calendar) days 12 hours

Radiography Work Permit Maximum 12 hours N/A

Electrical Work Certificate * No validity period N/A

* Supporting documentation has to be required at the same time of the Work Permit (general and/or hot)
for identifying particular hazards introduced by the work, which require further than formal controls.

Where such risks are identified, supporting Certificates are enclosed in the Work Permit.

6.8 Permit closure

The Permit to Work will be considered to be closed when YOUR COMPANY NAME’s Issuing Authority signs
the completion section of the Permit to Work (after receiving the subcontractor confirmation on the Permit
to Work that the work is complete). Acceptance of this signature is conditioned to:
 Completion of the work according to the instructions;
 Cleanliness of work area, including the removal of all the work equipment;
 Re-installation of all safety conditions.

6.9 Layout and Color of Permits

The Permits to Work are in A4 format and for visibility purposes, to aid identification of documents,
different colors are used on the border of Permits as per Figure 7.

Figure 7. Permit and Certificate Identification Color Codes

DOCUMENT BORDER COLOUR REFERENCE
Work Permit (cold) Black Attachment 1

Hot Work Permit Red Attachment 2

Confined Space Certificate Dark Green Attachment 3
Excavation Work Certificate Brown Attachment 4
Radiography Work Permit Bright-Orange Attachment 5

Electrical Work Certificate Blue Attachment 6

6.10 Permit and Certificate validity and endorsement periods

To ensure that precautions required for tasks of a long duration are reviewed regularly, limits are set on the
validity periods that Contractor Permit Coordinators may set for Permits, please refer to Figure 6.

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6.11 Permit to Work Procedure Auditing and Review
The objective is the periodically review and monitor the effectiveness and the application of this procedure.
The site will prepare an annual program of monthly compliance checks.

The program will:

 Identify those who will participate as lead auditors and audit team members;
 Have a minimum of one audit each month;
 Include all types of supporting Permits and Certificates;
 Include all areas of the site where the Permit to Work Procedure applies;
 Check that Permits are being displayed correctly in the Contractor Permit Coordinator Office;
 Confirm that the Permit to Work authorization register is up to date;
 Check that the Permits archiving is being done;
 Check by reviewing previous incident report statistics, that any incidents involving Permits have
been reviewed for potential impact on the Permit to Work Procedure.

A standard audit summary form will be provided and YOUR COMPANY NAME’s Construction Manager,
through YOUR COMPANY NAME’s FHSEC, is responsible for producing the action plan resulting from the
audit.

6.12 Emergency Response

Should any situation on site arise where there is a risk to personnel then the work shall cease immediately
and the response taken shall be in accordance with YOUR COMPANY NAME’s Emergency Response Plan.

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Attachment 1. Your Company Name Work Permit Forms

Work Order No.: _________________ Work Permit No.: ____________________________

Location: _________________
WORK PERMIT Issue Date: ____________________________
SUBCONTRACTOR ____________________________________AREA OF W ORK ______________________________________
SUBCONTRACTOR

WORK STARTING DATE _______________ TIME __________ WORK ENDING DATE _____________ TIME

________________ DESCRIPTION OF THE W ORK

_______________________________________________________________________________
___________________________________________________________________________________________________________

WORK EQUIPMENT _________________________________________________________________________________________

___________________________________________________________________________________________________________
Subcontractor receiving Authority _ _ _ Date Time _ _

The above signing person is responsible to ensure the work is performed under all the mentioned and required safety
precautions. Failure on this will be subject to disciplinary actions.

INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X):

TO BE FILLED BY CONTRACTOR

□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves

□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask
□ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness
□ Dust Mask □ □ □ □ __________

COMMON PROTECTION EQUIPMENT _________________________________________________________________________

__________________________________________________________________________________________________________

OTHER SAFETY MEASURES _________________________________________________________________________

__________________________________________________________________________________________________________

Contractor Issuing Authority ___________________________________________________Date ________ Time _________

Is Electrical PTW required Is Confined Space PTW required In case Electrical or Confined Space PTW
YES ___ NO ___ YES ___ NO ___ is required? YES ___ NO ___
PTW Number PTW Number If yes, attach a Copy.

Site Preparation completed and work can commence. I understand the precaution to be taken as described above.
Contractor Operating Authority Sub-Contractor Operating Authority
SANCTION AUTHORIZATION SIGNATURES
DATE TIME

The Work is completed and working area cleared The Site has been checked and working Area accepted
CLOSURE

____________________________________ _______________________________________
_ Subcontractor performing Authority _ Contractor Operating Authority

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 SUBCONTRACTOR TO BE FILLED BY

Attachment 2. Your Company Name Hot Work Permit Form

W work Order No.: W work Permit

_________________ Location:
HOT WORK PERMIT No.:_______________________ Issue Date
__________________ _ _
SUBCONTRACTOR _______________________________ AREA OF W ORK ______________________________________
WORK STARTING DATE ____________ TIME __________ WORK ENDING DATE ___________ TIME __________________
DESCRIPTION OF THE W ORK_____________________________________________________________________________
SOURCE OF IGNITION
_____________________________________________________________________________________ DRAW ING ATTACHED
______________________________________________________________________________________ WORK EQUIPMENT
____________________________________________________________________________________ Subcontractor receiving
Authority Date Time
Subcontractor performing Authority Date Time
The above signing person is responsible to ensure the work is performed under all the mentioned/required safety
precautions. Failure will be subject to disciplinary actions.

Has the equipment to be: YES NO CHK OTHER: YES NO CHK

TO BE FILLED BY CONTRACTOR

Depressurized Are sewer, drain properly secured

Drained Is Site clear from combustible
Isolated by spading Is Fire Protection required
Water flushed Is Fire Watch required
Ventilated by natural/mechanical Is Gas Tester required
Purged with inert gas/steam Specify how often gas tester is required
Other special precautions to be taken:
INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN
X):
□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety
Gloves
□ Welder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety
Glasses
□ Welder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S
Mask
□ Work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety
Harness
□ Dust Mask □ □ □ □ __________
GAS ANALYSYS TEST DATE TIME DATE TIME DATE TIME DATE TIME
COMBUSTIBLE
TOXIC H2S
O2
OTHERS

Signature Authority Gas Tester:

Site Preparation completed and work can commence I understand the precaution to be taken as described above
________________________________________________ _________________________________________________
Contractor Operating Authority Contractor Performing Authority

The Work is completed and working area cleared The Site has been checked and working Area accepted
CLOSURE

____________________________________ _______________________________________
_ Subcontractor performing Authority _ Contractor Operating Authority

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Attachment 3. Your Company Name Confined Space Work Permit Form

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 SUBCONTRACTOR TO BE FILLED BY

Attachment 4. Your Company Name Confined Space Work Permit

Work Order No: ________________ CONFINED SPACE WORK Confined Space Permit No:___________
Location: _ _ PERMIT Issue Date _______________________
SUBCONTRACTOR ______________________________ AREA OF W ORK
_________________________________________ WORK STARTING DATE _____________ TIME ________ W ORK ENDING
DATE ___________ TIME ___________________ DESCRIPTION OF THE W ORK
_____________________________________________________________________________
_________________________________________________________________________________________________________
WORK EQUIPMENT
_______________________________________________________________________________________
Stand-by W watchman Name Fire W watchman Name _
Stand-by W watchman Name shall record in/out of personnel; No one is allowed to enter without the presence of the Stand-by
W watchman
Subcontractor receiving Authority Date Time
Has the equipment to be: YES NO CHK OTHER: YES NO CHK
TO BE FILLED BY CONTRACTOR

Depressurized Are sewer, drain properly secured

Drained Is Site clear from combustible
Isolated by spading Is Fire Protection required
Water flushed Is Fire Watch required
Ventilated by natural/mechanical Is Gas Tester required
Purged with inert gas/steam Specify how often gas tester is required
Is power cable to be disconnected Is control cable to be disconnected
Is wind direction to be considered Are warning notice/area restriction required
Other special precautions to be taken:
INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN
X):
□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety
Gloves
□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety
Glasses
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S
Mask
□ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety
Harness
□ Dust Mask □ □ □ □ __________
GAS ANALYSYS TEST DATE TIME DATE TIME DATE TIME DATE TIME
COMBUSTIBLE
TOXIC H2S
O2
OTHERS

Signature Authority Gas Tester:

Site Preparation completed and work can commence I understand the precaution to be taken as described above

Contractor Operating Authority Subcontractor Performing Authority

The W work is completed and working area cleared The Site has been checked and working Area accepted
CLOSURE

_____________________________________ _______________________________________
_ Subcontractor performing Authority _ Contractor Operating Authority

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Attachment 5. Your Company Name Daily Permit to Work Review

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Attachment 6. Your Company Name Excavation Work Permit
Work Order No: ________________ EXCAVATION WORK Excavation Work Permit No: ___
Location: _ _ Permit Issue Date ___________________

SUBCONTRACTOR ______________________________ AREA OF W ORK ____________________________________

SUBCONTRACTOR

WORK STARTING DATE TIME W ORK ENDING DATE TIME

DESCRIPTION OF THE W ORK _________________________________________________________________________
Excavation by: HAND ____________________ EQUIPMENT ___________________ OTHER ______________
WORK EQUIPMENT _
Has the equipment to be: YES NO CHK OTHER: YES NO CHK
Is the excavation more than 1.2m depth Is a Confined Space PTW required
Is shoring, benching or sloping required Are nearby structures (buildings, equip.)
Are access ladders needed that would affect the excavation
Is road closure required Other special precautions to be taken:
Subcontractor shall provide along with the Excavation PTW also all necessary above and underground drawings
Subcontractor receiving Authority Date Time
Subcontractor performing Authority Date Time ________

SAFETY PRECAUTIONS
TO BE FILLED BY CONTRACTOR

□ Watchman □ Flagman □ Safety Signs □ Warning Tape □ Permanent barricade

□ Spoil clearance □ PPE □ Others
FACILITY
In case of presence of underground facilities, hand excavation must be done to expose them and after a Site Survey shall
be done by Subcontractor and Contractor to ensure all necessary precautions are taken and eventually allow mechanical
excavation.
Are the underground pipes, cables, etc. in the area exposed? □ YES □ NO
Are the underground pipes, cables, etc. within 15 m of existing facilities? □ YES □ NO
Are there any suspected facilities not identified in the drawings? □ YES □ NO
SITE SURVEY PERFORMED ON (date) _______________________ (time) ____________________
BY: CONTRACTOR______________________________ SUBCONTRACTOR ________________________________
Civil Department Mechanical Department
Signature ___________________________ Date _________ Signature __________________________ Date _________
Electrical Department Instrument Department
Signature __________________________ Date _________ Signature ___________________________ Date _________

EHS Department Others

Signature __________________________ Date _________ Signature ___________________________ Date _________

Is the Banksman required full time during excavation? □ YES □ NO _____________

Are hard barricades required to protect excavation? □ YES □ NO
Is warning tape required to highlight excavation location □ YES □ NO ____________________________
Is the spoil to be immediately removed from the working area? □ YES □ NO ____________________________
Excavation by hand only? □ YES □ NO ____________________________
Is the Area to be screened by cable detector before the work? □ YES □ NO _____________________________

The Site has been checked and working Area accepted The Site has been checked and working Area accepted
APPROVAL

__________________________ ______________________________________
SUPERINTENDENT CONSTRUCTION MANAGER OR DELEGATE

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Attachment 7. Your Company Name Authorization Signatures

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Attachment 8. Your Company Name Radiography Work Permit
Work Permit No:
Work Order No: ______________ RADIOGRAPHY
Location: WORK PERMIT Issue Date

SUBCONTRACTOR _______________________________ AREA OF W ORK ________________________________________

WORK STARTING DATE TIME __________ W ORK ENDING DATE ___________ TIME __________________
TO BE FILLED BY SUBCONTRACTOR

DESCRIPTION OF THE WORK _____________________________________________________________________________

OTHER PTW REQUIRED: Confined Space No. H o t W work No. ____________ C o l d W work No. ___________
Subcontractor receiving Authority Date Time
Characteristics of Radiation Equipment:
NUCLIDE SOURCE ACTIVITY Amount adsorbed in the air one meter from the active source X-Rays KV
GBq (Ci) 1 GBq GBq (1Ci) (Ci) mA
IRIDIUM 192 0,114 mGy/h mGy/h (420 mrad/h) (mrad/h) Directional
COBALT 60 0,311 mGy/h mGy/h (1150 mrad/h) (mrad/h) Panoramic
CAESIUM 137 0,078 mGy/h mGy/h (290 mrad/h) (mrad/h)
Intensity of Amount in the Air Per 1 m/A : mGy/h: (mrad/h):
Per m/A : mGy/h: (mrad/h):
Is Storage of the equipment foreseen in the Site Area? YES NO
SAFETY MEASURES
1) Exposure Time envisaged for the examination shown in Point A: min
Total amount envisaged, outside the enclosure, for the examinations shown in point A: microGy/h (__ mrad/h)
2) From the ratio between the maximum amount of 20 microSv/week and the total envisaged exposure time of hours/week, it is
established the intensity of outside the bounded area for unexposed workers, at m, must be less than ________ microGy/h
mrad/h)
3) Safety measures and signaling system: □ W work Clothes □ Safety Harness □ Dust Mask
□ Helmet □ Hear Protectors □ Safety Gloves □ Stand by person □ Shields
□ Climator □ Safety Shoes □ Safety Glasses □ Enclosure signs □ W warning lights
□ Protective Goggles □ Flashing lights □ H2S Mask □ □ __________
To be filled by Subcontractor’s qualified expert
Summary of the amount in the air and Exposure of this Intensity of the amount in Intensity of the amount in the air at
exposure times permit the air at the Area limit Area limit (time(1)+Intensity (2) =
micro Gy
Exposure Over 8
Date From hrs. To hrs. time Minutes hrs. microGy/h mrad/h microGy/h mrad/h

Subcontractor Qualified Expert Date Time

Subcontractor NDT Representative ____ Date ________ Time __________
Signatures above certify all Safety precautions/measures are on place and the work can commence
BYCONTRACTO

AUTHORIZATION FOR START THE W ORK

TO BE FILLED

Contractor Issuing Authority ______________________________________________________ Date ________ Time

__________ Special Safety precautions:
__________________________________________________________________________________
YOUR COMPANY NAME Construction Manager YOUR COMPANY NAME Area Superintendent YOUR COMPANY NAME HSE
Department
WORK COMPLETED
The work as above described in the mentioned Area has been completed and the Area is safe for normal working condition
Subcontractor Qualified Expert Date Time
Subcontractor NDT Representative Date ________ Time ______
Contractor Operating Authority Date Time

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Attachment 9. Your Company Name Electrical Work Permit
W work Order No: ELECTRICAL
W work Permit No:
Location: _________________ WORK PERMIT
_______________________ Issue Date
_________________________
SUBCONTRACTOR _______________________________ AREA OF W ORK_____________________________________
SUBCONTRACTOR

WORK STARTING DATE TIME WORK ENDING DATE TIME

DESCRIPTION OF THE W ORK
YES NO CHK YES NO CHK
Live work required Connected to ground/earth
Remote control isolated Lock Out/Tag Out in place
W warning signs & barriers erected Suitable access/regress provided/available
PPE required Other hazards
WORK EQUIPMENT _______________________________________________________________________________________
Associated W work permit: HOT No.: COLD No.: CONFINED SPACE No.:
Subcontractor receiving Authority Date Time
Subcontractor performing Authority Date Time

INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X):

□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves
TO BE FILLED BY CONTRACTOR

□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask
□ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness
□ Dust Mask □ □ □ □ __________
Is the prime mover to be isolated from mechanical motive power? □ YES □ NO Tag & Log Out No.:
Is the prime mover to be isolated from the other power source? □ YES □ NO Tag & Log Out No.:
Is the power cable to be disconnected? □ YES □ NO Tag & Log Out No.:
Is control cable to be disconnected? □ YES □ NO Tag & Log Out No.:

Additional Safety Precautions: ____________________________________________________________________________

Special Instructions to be followed in case of associated work permits (Hot, Cold, Confined Space):
The Equipment and/or location where the work is to be done has been inspected and the work is safe to do? □
SUBCONTRACTOR TO BE FILLED BY

YES □ NO Competent
Electrical person _________________________________________________ Date Time
Contractor Issuing Authority ___________________________________________________Date ________ Time ________

CLEARANCE
I hereby declare that the work is completed, all workers under my control have been withdraw and warned that is no longer safe
to work on the apparatus specified in this Permit of W work and that tools, temporary earthling connections have been removed
and the Site restored to safe conditions.

Subcontractor Performing Authority Date Time

CONTRACTOR
BY

I accept that the work is completed/suspended and the Site is restricted to a Safe conditions and the Apparatus is ready for restart
TO BE FILLED
OWNER

Operating Authority _____________________________________________________________ Date ________ Time ______

Competent Electrical person _____________________________________________________ Date ________ Time
_______

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