System / Component LOTO Isolation Permit Form

Permit No.:
SYSTEM / COMPONENT LOTO (ISOLATION) PERMIT
(Assigned by HSE LOTO)

SECTION 1 - Specification of Work (PERMIT REQUESTOR)

PERMIT REQUESTOR
Contractor Phone / Contact No.
Reason For Isolation- Full Description
Primary Equipment to be affected
Schematic Drawings & Diagrams (ref. No.): No MS/RA Ref. no., Schematic Drawings & Diagrams NO
PERMIT
Method statements Ref. No.:
Area (PIER 1,2,3,4, CP1 or CP2) Level
Gridline Reference Room No.
Date Expired
Date Received
(BY HSE LOTO)
Date Issued
SECTION 2 - Isolation Boundary Verification

I have verified the boundary and accepts responsibilities of the Isolations being requested.
Permit Requestor (PR) Print Sign
Name
Date:
Responsible Person (RP) Print Sign
Name
Date:
SECTION 3 - Permit Approval must be signed before permit is submitted to HSE LOTO Office

I, grant permission for the work to proceed Subject to all conditions from the checklist are met. I reviewed and check all associated test packs are approved. I declare that all information given in this permit is
true and correct.
Sign
Manager / Area Supervisor Temporary
Electrical Department (TEMPORARY POWER)
Print Name
Date:
Subcon- T & C / Start up / MEP Manager Sign
Print Name
Date:
MAIN CONTRACTOR / Start up / MEP Manager Sign
Print Name
Date:
SECTION 4 - SAFETY TAGGING / SIGN ON SHEET (SEE SECOND PAGE)

SECTION 5 - TAGGING AUTHORITY (TA) - HSE LOTO DEPARTMENT must be signed before permit is ISSUED to AUTHORIZED PERSON / REQUESTOR

I have checked that the Isolation Points identified in the Safety Tagging Permit Requestor (PR) is sufficient and authorize the work to proceed.
HSE LOTO TAGGING AUTHORITY Sign
Print Name
Date:
SECTION 6 - COMPLETION, SUSPENSION OR CANCELLATION of WORK
All work associated with this Electrical Permit has been:

COMPLETED * CANCELLED * SUSPENDED *

All work associated with this Electrical Permit has been:
Additional Comments:

Sign
Authorized Person / Permit Requestor (PR)
Print Name

Date:

AFET-IMS-F253| HSE | Permit – System / Component LOTO Isolation Permit Form| Issue 1 | Rev 0 | Jun '17