TEPL Green Field Project –JASMINE, Hosur, Tamilnadu

Client: TEL Components Pvt Ltd

PMC: TATA Consulting Engineering Ltd
Contractor: KIRBY
PERMIT TO WORK- WORK AT HEIGHT
Permit No:
Section – I GENERAL DETAILS
Project Name
Activity/Type of work
Area/Location
Date : Time From: AM/PM To: AM/PM
Permit Applicant Name
Contractor Name
Section – II PRECAUTIONS TO AVOID POTENTIAL HAZARDS
PRIOR TO COMMENCEMENT YES/NO DURING EXECUTION YES/NO
Hazard identification and assessment of risk All persons subjected to falling risks are
/JSA attached to work permit and equipped with Personal Fall Arrest
communicated to workers involved System
Scaffolding/ working platform is provided with All personnel are adequately trained to
access ladder, railings, toe boards and green tag Perform work at height
provided after inspection by competent person
Edge protection provided wherever No access zones below work area
there is falling hazards Unauthorized entry restricted
Fall prevention equipment are adequate and in Cautionary signage are provided below
good condition or surrounding area
Adequate supervision provided from
Anchorage / Lifeline installed and inspected by
Contractor’s side to monitor safe
competent person
Working. Name:
……………………………
Section – III (Permit Requested by):
I request a permit for the above mentioned work at the location specified above. I have personally inspected the work
place to ensure that requirements needed and precautionary measures as mentioned above have been complied with
Checked by Name Designation Signature
Contractor site In charge

Acknowledged by EHS Contractor

Authorized by Issuing authority Name Designation Signature

(Area Manager)

Name Designation Signature

Acknowledged by EHS

Section – IV PERMIT CLOSURE

The above job have been completed at, Time: …………………….. and ensured area is safe
Permit tee (Name)…………………….………Signature :………………………..Date & Time:……………………..
 The above work is completed, permit closed & permit submitted to EHS.
Issuing authority (Name): ……………………Signature: ……………………. Date & Time: ………………….…