PERMIT TO WORK

Staircase (All Works)

Project : Permit No :
Company : Date :

SECTION I PERMIT REQUEST

Description of Work: _________________________________________________No. of personnel involved: ______ (List on reverse)

Location:  Tower  Podium Floor Area:______________________________ Staircase __________________________

Duration of work - Date: _______________ from ________hours to _________ hours.

Safety Requirement Checklist

Yes N/A Yes N/A
2. Competency of Operatives- The entire crew
1. Safety Induction- All crew members have completed
including supervisor are trained, competent and have
safety induction.
valid 3rd party certificates.
3. Method Statement & Risk Assessment (MSRA)-
MSRA have been addressed to the entire crew and
4. Working Platform: Proper working platform available.
all are fully aware of the precautions and procedures.
MSRA copies available with the supervisor.
5. PPEs- Required PPEs are available as per MSRA.
6. Access- Safe and clear access available.
Safe places available to book safety harness.
7. Overhead Protection- Available. 8. Light- Sufficient Task light available.
10. Tools-
 All tools are well maintained and in good
9. Ventilation- Work area is well ventilated. condition. String/Rope available to secure.
 Electric cables are not damaged will be routed
correctly.
11. Hot Work- Separate permit for Hot work will be taken
12. Equipment- well maintained and in good condition.
and followed.
13. Supervision- Full time supervision will be available. 14.
15. 16.

Important Instructions (Read and Tick )

* Permit is issued only for a shift (day /night).
* Permit should be available and displayed at workplace till completion of work.
* Permit extension is allowed only for one time till the end of same shift.
* Site Manager, Engineer, Supervisor and Safety Officer must inspect the workplace to ensure the correct implementation of
permit to work.
* Permit to work will be suspended by the inspecting official if any non-compliance noticed.
* Permit should be closed-out upon completion of work and handed over to Safety office on the same day.

Declaration of Work in Charge

I hereby declare that:  the above requirement / precaution are in place and addressed to the team and we are fully aware of the
same.  I will be responsible for the proper implementation of this permit  _________________________________________

Work-in-charge (Name): __________________________ Signature: _________________ Date: __________________

Site Manager / Engineer (Name): __________________________ Signature: _________________ Date: __________________

Safety Officer / Representative (Name): __________________________ Signature: _________________ Date: __________________

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SECTION II PERMIT ISSUE
This Permit is valid till (Date): Time: hours
Site Manager / Engineer Safety Officer

Name: _____________________ Signature: Name: Signature:

SECTION III CREW DETAILS

Sr. No Induction Number Name of Operative Designation / Trade

1.

2.

3.

4.

5.

6.

7.

Note: Attach separate sheet if necessary

Work-in-charge (Name): ______________________ Signature: _______________________

SECTION IV PERMIT INSPECTION
Name Designation Company PTW Date Time Signature
Compliance
(Yes / No)

SECTION V PERMIT CANCELLATION

This permit is cancelled due to :-  Recommend precautions not in place  Others (Specify) _________________________

Cancelled by Name: ___________________ Signature: ______________ Date: _____________ Time: ______________

SECTION VI PERMIT EXTENSION

Request to extend the Permit till (Date): _________________ Time: ____________ hours.
Time:
Work in charge / Site Engineer Safety Officer

Name: _____________________ Signature: ___________ Name: __________________ Signature: _____________

SECTION VII PERMIT CLOSURE

It is to confirm that the work completed on _______________at _______ hours  The area inspected and found safe  Permit closed
at ______________ hours.

Work in charge (Name): ___________________ Signature: _____________ Date: _____________ Time: _____________

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