Permit for working on low voltage circuits Form SMM 17

Ship name: ………………………….. Date: …………………………

Port / position: …………………. Permit no: .………………….
This permit is valid from: ………………. Hrs on date: ……………………..
To: ……………… Hrs on date: …………………….

This permit applies to low voltage circuits of less than 1000 Volt AC.
Work is planned on Circle selection:
 Dead line
 Live line
 Close proximity of life line

Define the scope of work

Nature of the work planned
What equipment / circuit will you work on
Working voltage of the equipment
Location of work
Location if free of hazards:
 Excessive humidity
 Toxic gases
 Very high or low temperature
Is the work plan agreed by all persons involved in the
work?
Are the proper tools available and in use?
Is the correct PPE worn?
Are all other required permits completed? Permit numbers:
Was a risk assessment carried out? RA number:
Method of isolation agreed Method:
Power supply tagged out by Name / rank
Power supply tagged out at Date / time
Name / rank of persons carrying out the work
Name / rank of person authorising the work
The undersigned are satisfied that the circuits described above have been sufficiently isolated and that it is
safe for the work outlined to commence.
Signature of person / team leader carrying out the work:
Signature of Chief Engineer
Signature of Master
Permit closed at Time: Date:
Signature of person authorising
the work
Master’s signature

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