COMMISSIONING SAFETY RULES

Section 1 : Request for Work Permit PERMIT TO WORK PTW NO :

1. Location Equipment
2.Unit
3.Work Description

4. Estimated Duration : From Date : To date : Time :

5. Type of Work Permit Required to perform Job:
Permit for standard
operational
Confined space activities
Permit to work
permit

Live work
Hot work permit Caution Tag
certificate
Request
( Please justify below if live work certificate is required ) : ________________________________________________________________

JSA Submitted YES NO

6.Requested by ( Authorized contractor Supervisor ) : Name Date : Time : Signature :
Section 2 : Isolation
1. Isolation as per switching order 9 Attach separate sheet if required , Attachment - c)

Equipment Status after Lock / chain

Sl No Key safe No.
identification/ KSS No Isolation tag
Isolation on by DP Isolation verified by DP
Sign Date Time Sign Date Time

2.Other PTW lockout / Tag Out attcahed with this permit : ___________________________________
3. Permit validity : From Date : ___________ Time :____________ To, Date :___________ Time : ___________
4. Other permit to work attached : _____________________________________________________________________________________________
5. PTW Prepared by AP : Name : _______________________________________________________________________________________________
6.PTW Authorized by Sr. ap ; Name : __________________________________________________________________________________________
3. Receipt
I hereby declare that | understand that the apparatus specified on this Permit-to-Work Is safe to work upon in accordance with the Start-up
jand Commissioning Safety Procedures and | have verified the listed equipments isolation.
PTW Accepted by ACS : Name : ____________________________________________ Date / Time : __________ / __________ Signature : _______
2.Purpose : _______________________________________________________________________________________________________
3. Extention required from : Date : __________ Time : ___________ To , Date :____________ Time : ___________
4.PTW Extention Authorized by AP : Name : _______________________________ Date / Time : _________ / _________ Signature :______________
5. Transfer
I hereby declare that | understand that the apparatus specified on this Permit-to-Work transferred to me is safe to work upon in accordance with start-up and
Commissioning Safety Procedures.
4.PTW Accepted by ACS : AP Name : _______________________________ Date / Time : _________ / _________ Signature :______________
5. Suspension
I am as Authorized Contractor Supervisor hereby declare that all employees under my charge have been withdrawn and warned that it is no
longer safe to work on the apparatus specified on this Permit-to-Work due to ____________________________________________________________
4.PTW Reissued by ACS : AP Name : _______________________________ Date / Time : _________ / _________ Signature :______________
6. Clearance / Work Completed :
I am as Authorized Contractor Supervisor hereby declare that all employees under my charge have been withdrawn and warned that it is no
longer safe to work on the apparatus specified on this Permit-to-Work, that all gear and tools are dear, all guards have been replaced and loose

PTW Closed by ACS : AP Name : _______________________________ Date / Time : _________ / _________ Signature :______________
7.Cancelation
1.Normalization as per below switching order (Attach separate sheet if required, Attachment -z)

Sl no Normalization verified by DP
Equipment Status after Lock /Chain,
identification/ KSS No Normalization TAG

I am as Authorized person hereby declare that this permit and all copies are cancelled
PTW Cancelled by AP : AP Name : _______________________________ Date / Time : _________ / _________ Signature :______________