Electrical Energization Permit Form

Commissioning

This Form should be used in accordance with the Electrical Safety Standard (MS-HS-STD-0065).
Project Details
Contract No. [Insert Text] Permit No. [Insert Text]

Site [Insert Text]

All Work Under This Permit Requires A Valid Clearance Certificate

Requested By Date
Contractor Area/Location
Description of Work
______________________________________________________________________________________________________
Equipment to be energized: ___________________________________________ (State Plant Item Numbers, where possible)
Precautions and Authorizations
Isolation (Identify isolations and state whether or not isolators have been padlocked off for another Apparatus, key No.
_______________, fuses drawn, rubber mats in place at MCC etc.)
______________________________________________________________________________________________________
Warning Notices and Access Control (State whether Caution/Danger Notices have been posted and, if appropriate, how work areas
have been fenced off)
______________________________________________________________________________________________________
Prove Apparatus Tested or Attach Certificate of Test of Electrical Installation (DD40/1) (State what test have been made, where
and with what instruments)
______________________________________________________________________________________________________
Communications (Authorized person in control room and equipment area notified, radios to be used etc.)
______________________________________________________________________________________________________
Other Permits to be Withdrawn (Identify by Permit No.)
______________________________________________________________________________________________________
Other Precautions (Specify if required for special circumstances)
______________________________________________________________________________________________________
I declare that the above isolations have been made and made known to the competent person in charge of the work. I consider that
the equipment specified is safe to ENERGIZE.

Signature of the authorized person(s): _________________________________ Time (hrs.) ___________Date: _______________

Acceptance and Receipt
I acknowledge receipt of this permit and understand the safety precautions described above. Neither I nor the person under my
control will work on / test any other electrically dangerous apparatus. I will return this permit to the Authorized Person when the
work / test has been completed.
Signature (competent person) Time (hrs.) Date Click or tap to enter a date.
Clearance of Work
I declare that the work / test detailed has been completed / stopped; and workforce / gear withdrawn.
This apparatus is to remain energized. Yes No
Signature (competent person) Time (hrs.) Date Click or tap to enter a date.
Cancellation
I declare this permit cancelled.
The equipment specified has been de-energized and isolated. Yes No
Signature (Authorized person) Time (hrs.) Date Click or tap to enter a date.

Effective Date at JESA: 20 January 2021 MS-HS-FRM-0024 Rev 0 01 December 2019