Permit to Work

Hot Works

Area: Date and Time:

Scope/Type of Work:
Equipments to be used:
Duration of work:

NO WORK OUTSIDE THIS SCOPE MAY BE PERFORMED UNDER THIS PERMIT

Hazard likely to be encountered:

PRECAUTION OR SPECIFIC REQUIREMENTS

Y N Y N
Fire Observer/s Contain all sparks
Check Combustibles Gas/Flammable Liquid (15m radius) Fire blankets
Check Combustibles Surrounding area (10m radius) Signs erected
Check Combustibles Floors Below (10m radius) Barricade area
Fire check of area after work
Extinguisher at hand
complete
Run out water hoses 2 hr closure time required
Area wetted Gas testing
Ancillary Supply
Gas Test Frequency: Maximum LEL Permitted:
Initial Gas Test: Date: Time:

THE AREA IS IN A SAFE CONDITION FOR HOT WORK TO BE CARRIED OUT PROVIDED THE PRECAUTIONS
AS STATED ARE COMPILED WITH

Issuer Name: Date: Signature:

I ACKNOWLEDGE RECEIPT OF THIS PERMIT AND FULLY UNDERSTAND THE CONDITIONS AND
PRECAUTIONS REQUIRED

Acceptors Name: Date: Signature:

WORK COMPLETED:
Fire check made of area, work associated with this clearance certificate is complete, safe & no further work is required

CERTIFICATE CLOSED

Name: Date: Signature:

Hot Works

SIGN ON
I fully understand that all the hazards of this job and all of the conditions I must follow to ensure the safety of
myself and my co-workers.

Name Date Company Initials Name Date Company Initials