LARSEN & TOUBRO LIMITED

BUILDINGS AND FACTORIES INDEPENDENT COMPANY

Permit Serial Number: Ref: CP 02-1 Rev 01

CONFINED SPACE ENTRY PERMIT
Date:
A. Applicability:
The scope of this permit is limited to entering into confined space. Relevant work permits shall be obtained for
carrying out the activities inside the confined space along with this permit.

B. The Person Requesting Permit (Permittee) to fill up

1. Identity of the Confined Space
2. Location
3. Purpose of Entry
4. Validity of Confined Space Permit From: Date ………….. Time: …………..
To : Date…………....... Time: ……………

5. The following points were checked and adequate safety measures are in place
 The place/equipment/space been cleaned, purged, isolated
 Proper access/egress to confined space is available
 Adequate ventilation like exhaust/fresh air flow fan provided
 Adequate lighting is made available/24V hand lamp provided
 All workers are provided with the necessary PPE and external training
 Rescue team and emergency devices are placed as standby
 Risk Assessment has been carried out and briefed to the workers
 Safe Work Procedure is available and briefed to the workers
6.
7. The following test has been conducted and confirmed that the above recommended safety measures are
in place and the said location is safe for work at the point of inspection.
 Confirmed gas within limits (Combustible: ____%LEL, H2S : ____PPM, CO: ____PPM)
 Confirmed adequacy of oxygen in confined space. (O2 : ______%)
 Temperature
 Air Flow
 Lighting

8. List of authorized persons work inside confined space & Rescue team list is enclosed

The above points have been checked and complied with and it is safe to undertake the work, so I request to issue
permit to carry out the work

Name of Permittee _______________ Signature_______________ Designation________________

(Site engineer)

C) Verification by EHS Personnel

I have verified the safety arrangements and found satisfactory to carry out works

Name & Signature of verifying EHS Personnel _______________________________________

Signature Date Time

D) The Person Authorizing Permit (issuing authority) to fill up:

I have cross checked that all above precautionary measures have been complied.

Name & Signature of issuing authority ____________________________________

Section In-charge Date
E) Permit Closure
The above work was completed safely and this copy the permit handed over to EHS Department for file

Signature of Permittee : _______________ Signature of EHSM/ EHSO:________________

Date : Date :