Ref No.: HSE/CTN/HPP/FMT/ 010 PTW NO:-…………….….

Permit To Work - LIFTING WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance of the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________

Name ( in block letters) / date/ signature Date / Time / Sign

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of extension
Date / Time / Sign
required authorization as above is " MUST".
LIFTING WORK - Check Points
Any work on ground level where there is risk of personal injury while carrying out the work.

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted
1 YES NO N/A
(Attach Attendance)
2 Experienced and trained operator and signalman deployed for rigging operation YES NO N/A

3 Job Specific PPE's provided to the enagaged team. YES NO N/A

4 Lifting gears & appliances being used are safe to use and TPI certified. YES NO N/A

5 Proper rubber packing to lifting material and Tag Line used during lifting operation. YES NO N/A

6 Adequate access provided to work location. YES NO N/A

7 ASLI & Limit switches of equipment are functional. YES NO N/A

8 Unauthorised entry restricted & area cordoned off during erection / lifting. YES NO N/A

9 lifting of load found as per equipment load chart. YES NO N/A

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing Emergency Vehicle Weather Condition Medical Fitness

v v
v Other (Please Specify):
Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as property. I
will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : ____________________________________________
Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action
Contractor EHS Engineer / Manager : - ______________________________________
Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature