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PROJECT name

COLD WORK PERMIT

PERMIT NO. COMPANY: MANPOWER:
START DATE: FINISH DATE: TIME FROM: TIME TO:
LOCATION: Department:
Section A: SAFE WORK PLAN
Authorized Person: Position: Phone#:
Description of Work:

S/N HAZARDS PRECAUTIONS

Section B: HAZADS IDENTIFICATION CHECKLIST (Tick Where Appropriate)

Y N N/A Pre Job Start Meeting Y N N/A Barriers & Protection Required
Y N N/A Emergency Instruction Required Y N N/A Fire Extinguishers Required
Access is clear and free of obstruction. Access Cables/cords are raised 6ft. above surface and
Y N N/A Y N N/A
ladder is secured and free of defects. safety flags are provided
Full body harness with 2 lanyards and shock absorber Open areas are adequately covered and protected.
Y N N/A Y N N/A
worn where required. 100% PPE compliance. Warning signs are conspicuously posted
Safe Work Plan submitted alongside with cold work Walkway is clear of scattered debris, tools and
Y N N/A Y N N/A
permit. materials
Y N N/A Working Alone Y N N/A Information of other affected personnel is required.
Y N N/A Illumination Required Y N N/A Proper and adequate housekeeping is maintained.
Elevated work will not be performed above fuel Elevation Work has safe access and egress and
Y N N/A Y N N/A
driven equipment. secures anchor points.
Section C: Acceptance: - I accept responsibility for the work / personnel started. Agree to implement safe working procedures
and confirm that all personnel are adequately trained and will work only on the job / equipment specified.
NESMA PERMIT RECEIVER NESMA SITE ENGINEER
NAME (Please Print): NAME (Please Print):

SIGNATURE: DATE: SIGNATURE: DATE:

Section D: APPROVED BY
NESMA SAFETY SUPERVISOR/OFFICER: NESMA PERMIT ISSUER
NAME (Please Print): NAME (Please Print):

SIGNATURE: DATE: SIGNATURE: DATE:

Section E: EXTENSION OF WORK PERMIT

NESMA CM/PROJECT ENGG/SITE ENGG/ NESMA SAFETY SUPERVISOR/OFFICER
NAME (Please Print): NAME (Please Print):

SIGNATURE: DATE: SIGNATURE: DATE:

Section F: CLOSING OF PERMIT

Permit Closed Receiver : Date/ Time
Issuer: Date/ Time
NOTE: (1) This permit must be submitted to the NESMA SAFETY DEPT. before 24 hrs.
IF EMERGENCY ALARM IS SOUNDED, THIS PERMIT IS CANCELLED