This permit is valid for a maximum 12 hour shift Permit No.

COMPANY
HOT WORK PERMIT
HW-

1) Description and Location of Work Number in Workgroup:

( TO BE COMPLETED BY THE WORKGROUP LEADER)

Name : Department/ Company : Signature : Date :

2) Adjacent Workgroups ( Location ) ( TO BE COMPLETED BY PERMIT CONTROLLER)

Accompanying Permit / Certificate Numbers

Type Number Type Number
Hot Work Electrical Isolation

Cold Work Mechanical Isolation

Entry Certific. Risk Assessment

3) P.P.E. / Safety Equipment / Extra Precautions * ( EYE PROTECTION MUST BE WORN AT ALL TIMES )

Safety Harness Radio Inertia Reel

Goggles Fire Extinguishers Firewatch
Ear Protection Warning Signs / Barriers Charged fire hose
Gloves Gas Test Fire blanket
Additional Precautions :

* = Tick as applicable Name : Signed :

( TO BE COMPLETED BY PERMIT
CONTROLLER) Date :
4) Duration of Permit Time start………………………..……Time finish……………………………………….
Issued to Initial Issue Gas test By Equipment Locked out/tagged out
Name #
Signature #

Fire Officer’s
signature
Task Complete or Operations Supv sign off
ongoing (delete)
Signature # Signature
(Permit Returned)
Signature (# = Workgroup Leader) Signature (## = Permit Controller) Signature (### = Competent/
By signing this I accept thatI will abide by all By signing this I accept that I am responsible for Authorised Person)
rules and regulations stated on this permit to all the above precautions being in place By signing this I confirm that an
work isolation is complete

5) Permission to Start Work Name : Signature : Date :

(# # # Area Authority)
By signing this I accept that I am ultimately
responsible for the permit and the work being
done under it

[ Original to be held at worksite, first copy to be held by Permit Controller, second copy to be held by Area Authority ]

Form : HSF 62 QSE P002.4-(Hot Work Permit)