SIEMENS Ltd. General Work Permit Serial No.

Work Issuing Authority Fill up the work permit Signature of Permittee / Signature of Dept. Head in Signature of Unit Safety
(Permit Issuing Officer) along with working Working Agency whose area work is to be Co-ordinator.
(Siemens Official) agency (contractor) (contractor), Permit issuing carried out.
officer

Exact Location of Worksite/ Work place:_______________________________________________________________

Permittee / Working Agency (Name of Contractor): ___________________________________________________

 Manual Material Handling 

Type of Work: Use of Portable Power Tools Carpentry Work  Civil work at ground level 
Material Handling by Crane  Gardening Work & Tree Trimming Work  Painting Work at Ground level  AC Maintenance 
Any other Work , specify ________________
Description of Work:__________________________________________________________________________________________
___________________________________________________________________________________________________________
Start of work: _____________ _____________ End of work: _____________ _____________
Date Time Date Time
Work of this nature must not be started until this permit, with the required signatures, has been obtained and the defined safety measures have been observed.
In all cases this permit is only valid on the day/s for which it was issued and for the worksite entered. If the same worksite exists at the same place for a longer
duration, the Permit Issuing Officer/Authority may extend the permit to a maximum of three weeks. Once this period is expired, the permit must be renewed in
each case.
A. Following safety precautions are taken care off.
Sr. Safety Precautions Yes No Not
No. Applicable
Work Preparation
1. Material at worksite is properly segregated & kept at allocated space.   
2. Supervisor at site is monitoring the HOUSEKEEPING on daily basis.   
3. Site supervisor is ensuring Safe Access at all workplaces.   
Use of Portable Power Tools
4. Electrical connections are given through two /three pin industrial socket.   
5. All electrical portable hand tools are inspected before put in use. Sign of Unit   
PE________________ Sign of Permitee________________________
6. Persons doing grinding, drilling work are using safety goggle.   
Manual Material Handling Safety Precautions
7. Weight of material is not exceeding the 55 kg for male adult & 30 kg for female adult.   
8. Material is checked for oily surface, dust before lifting & cleaned accordingly.   
9. Material transport route made free from obstructions before handling.   
10. Safety shoes & hand gloves are provided & the supervisor ensures its use.   
Carpentry Safety Precautions
11. All tools are inspected on daily basis.   
12. Wooden blocks, battens are always kept well supported to prevent fall.   
13. Wood sawdust is removed on daily basis.   
14. All persons engaged in doing nailing / hammering activity are wearing safety goggles.   
Civil Work (at ground level):
15. All persons are wearing safety shoes, hand gloves, and helmet.   
16. Persons engaged in stone breaking, chipping, drilling, hammering activity are wearing safety   
goggles.
17. Bricks are stacked not more than 2 metre height.   
18. Helper (cleaner) is provided for each Truck / Tractor or other vehicle at site.   
19. Cleaner is guiding the driver while reversing the vehicle.   
20. Persons engaged in shuttering work are wearing safety goggles.   
21. For asphalting work, all flammable material is removed from the place of heating process of   
bitumen.
Safety Precautions for Material Handling by use of CRANE
22. All lifting tools & tackles (crane, wire rope sling, chain sling, chain pulley block, D-shackle etc)   
are having VALID test certificate (FORM 12) issued by Competent Person approved by
Directorate of Industrial Safety & Health.
23. Safe Working Load of Crane (at any angle & at required boom length) is more than load to be   
handled.
24. Chain pulley, rope etc not to be tied to truss / perlin for lifting the material.   

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 25. Area is barricaded.   
26. No person is allowed to enter the crane boom radius area.   
27. The riggers are experienced & having adequate knowledge of safe rigging practices.   
28. Material raised by the crane is tied by the guide rope. The other end of guide rope is with the   
person walking along crane.
29.
30. In case of stationed crane, the outriggers are rested properly on firm soil with base plate.   
31. Site supervisor is present on site while doing material handling by use of crane.   
Gardening Work & Tree Trimming Safety Precautions
32. All persons doing gardening work are using gumshoes.   
33. Water used for gardening is not spilled on road.   
34. Writing permission is obtained from Municipal Corporation for tree trimming work.   
35. Person climbing on tree is wearing full body safety harness & anchoring it to rigid support.   
36. Area below the tree to be trimmed is barricaded & entry of any person in barricaded area is   
prevented.
37. Branch to be trimmed is tied to tree with rope before start of trimming work.   
Painting Work at ground level
38. Paint containers are stored in cool dry & ventilated place.   
39. Person applying paint is wearing hand gloves, safety goggle, and safety shoes.   
40. Painting activity not carried out near hot work (welding, gas cutting, grinding)   
41. Left over paint / waste paint / thinner not thrown in drain. It is treated as hazardous waste & to   
be sent to scrap yard for scientific disposal.
42. All empty paint containers are to be taken out of the Siemens premises.   
AC Maintenance
43. Isolate electric supply before start of work.   
44. Person doing filter cleaning is wearing dust mask.   
45. Person working at height on cooling tower is wearing full body safety harness & anchoring to   
fixed rigid support. He / they are wearing safety helmet.
46. Hazards arising out of this activity are incorporated in HIRA sheet
Safety Precautions for Any Other Activity
47. Details of Any other miscellaneous activity (other than as listed above)
__________________________________________________________________________
Safety Precautions to be taken-
1. _______________________________________________
2. _______________________________________________
B. Number of persons working for this job____________________

C. PPEs required during work (Tick mark whichever is required & provided)
PPE provided: Safety helmet  Safety goggles  Safety Shoes  Dust Mask  Full body safety harness 
Hand gloves  Specify any other PPE required _____________________________________

D. I have confirmed that above requirements have been complied with.

Permit Issuing Officer: Name:______________ Signature: __________ Date:_____ Time:____ Intercom:_____
(Work Issuing Authority/Siemens Official) ______________________________________________________________________________________________
I confirm that I have been placed in direct & continuous charge of the work specified above. I shall take all necessary precautions to
Avoid danger. Only trained persons will be assigned for this work.
Permittee (Working Agency / Contractor): Name:__________________ Signature: ___________________

Date:_________ Time:___ Mobile No:____________________________

__________________________________________________________________________________________________________
HOD in whose area Work is carried out: 1. Name____________________ Signature______________ Date________
2. Name____________________ Signature______________ Date________________

We are satisfied with above-mentioned precautions. Special precautions to be complied with:__________________________________

____________________________________________________________________________________________________________
Unit Safety ________________ ________________________ _______. ________________
Co-ordinator: Date Name Signature
E. Safety measures on completion of work
1. Waste cleared from work site /work place. Yes  No 2. PPEs returned to Auxiliary store Yes  No
___________________________________________________________________________________________________
F. Tool Box Talk conducted (Original records shall be produced at the time of receiving permit.)
 Manual Material Handling  Material Handling by crane  Use & importance of PPEs
 Hand tool Safety  Safety in Height Work

G. Permit renewal (To be signed by permit issuer in each week of the month.)
Sr. No. Date Name of Permit Issuer (Work Issuing Signature Name of Permittee (Working Signature
Authority / Siemens Official) Agency / Contractor)
1.
 SIEMENS Ltd. General Work Permit Serial No.:

2.
3.
1st copy (White): Working Agency ; 2nd copy (white): Work Issuing authority; 3rd copy (white): Safety Dept. (CORP/OSE) / SHE Co-ordinator

IN CASE OF FIRE CALL- 3333

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