Document Title –Permit For Work At Height

Document No. HGC/HSE/PTW/WAH Ref. No. 001 Issue Date 15 JANUARY 2021

PROJECT SITE / PLANT NAME CVF PTW NO

DATE OF APPLICATION 18/01/2023

APPLICANT COMPANY TMI- DEFAB
LOCATION OF WORK CVF
WORK TO BE PERFORMED INSTALLATION
DURATION : FROM 18/01/2023 TO 18/01/2023 TOTAL DAYS 1 DAY
START TIME 07:00 AM STOPPAGE TIME 08:00 PM
LIST OF MACHINERY / EQUIPMENT / WORK TOOL TO BE USED
1. SCAFFOLDING 4. DRILL MACHINE
2. WELDING MACHINE 5.
3. GRINDER MACHINE 6.
If Mobile Elevating Work Platform Using () Authorized Operator Name
THIS PTW CAN BE WITHDRAWN AT ANY TIME IF ANY SAFETY CONDITION IS NOT MAINTAINED. IT IS VALID ONLY FOR THE
DURATION STATED ABOVE. THE APPLICANT OF THIS PTW SHALL BE RESPONSIBLE FOR MAINTAINING A COPY OF THIS PTW
AT THE LOCATION WHERE THE WORK IS BEING CARRIED OUT AND MUST PRODUCE IT UPON REQUEST. THE APPLICANT OF
PTW SHALL BE RESPONSIBLE TO NOTIFY THE AUTHORIZED APPROVAL UPON COMPLETION OF WORK.

SAFETY PRECAUTIONS TO BE COMPLIED WITH PRIOR TO PERMIT APPROVAL

SN SAFETY PRECAUTIONS YES() NO() NA() REMARKS
O
1 All person subjected to falling hazards are adequately trained 
to perform work at heights?
2 Safe means of access / egress provided? 

3 Emergency Response Procedure for WAH activities developed 

and communicated to workers?
4 Are PPE provided – safety harness, helmet (with chin straps), 
safety shoe, googles, cut resistance gloves, face mask Etc.?
5 Fall Protection Plan & Risk Assessment conducted and 
communicated?
6 All person subjected to falling hazards are equipped with 
Personal Fall Arrest System?
7 Are working platform, guardrails, toe-board, are adequately 
intact?
8 WAH Permit displayed on site for the duration of the 
approved task and removed only upon task completion or
upon its expiry?
9 Weather condition suitable for the work? 

10 Fall prevention equipment’s used to access/ egress work 

platform?
11 Edge protection provided wherever there is falling hazards? 

12 Workers are in good health to work at height? 

13 Is high level of supervision provided during work at height? 

APPLICATION FOR PERMIT TO WORK FOR WORK AT HEIGHT

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 Document Title –Permit For Work At Height

Document No. HGC/HSE/PTW/WAH Ref. No. 001 Issue Date 15 JANUARY 2021

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 Document Title –Permit For Work At Height

Document No. HGC/HSE/PTW/WAH Ref. No. 001 Issue Date 15 JANUARY 2021

LIST OF WORKERS INVOLVED

SNO NAME OF WORKERS LEVEL OF WORKERS SIGNATURE
1 SHARAFAT ALI WELDER SUP.
2 VIKAS WELDER
3 RAMPRAVESH WELDER
4 SALEEM WELDER
5 ASHOK WELDER
6

APPLICANT (SUPERVISOR OF PERSON(S) WHO IS TO CARRY OUT WORK AT HEIGHT:

I confirm that safety measures are implemented before making application for the permit.
NAME SHARAFAT ALI DATE & TIME 18/01/2023 / 08: 30 AM
DESIGNATION SIGNATURE

APPROVED BY :AUTHORIZED MANAGER

NAME MR.LEO DEVELOS DATE & TIME 18/01/2023 / 08: 30 AM
DESIGNATION SIGNATURE
FOLLOW-UP AND INSPECTED BY SAFETY OFFICER / ASSESSOR
NAME SIGNATURE

DATE TIME

Instruction :

NOTIFICATION OF COMPLETION OF WORK BY APPLICANT

The above was completion on (Date & Time)
NAME TIME
DATE SIGNATURE
ACKNOWLEDGED OF COMPLETION (BY AUTHORIZED MANAGER)
NAME TIME
DATE SIGNATURE

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