Procedure #_ Job/Work Order No

Department Code Permit # ENERGIZED ELECTRICAL WORK PERMIT

PART I: TO BE COMPLETED BY THE REQUESTER:

(1) Description of circult/equipmentjob location:.

High voltage: Low voltage:

(2) Description of work to be done: .

ustncaion or why the ircuit/equipment cannot be de-energized or the work deferred until the next scheduled oulage
(3)

Date
Expire Date Requester/Title
Start Date
DOING THE WORK:
PART I: TO BE COMPLETED BY THE ELECTRICALLY QUALIFIED PERSONS
hazards, conditions, mechanica,
detailed work including
jod description procedure to be used in performing the above
Detaled
environmental, space obstructions, other voltages

Notity affected workers -

LOTO Two Workers Safety Watch
4Descnption ofthe Safe Work Practices:
Reason not to LOTO

Restart Checks Required

Working Distance
(3) Shock Hazard (max V)_ Glove Class, minimum
Flash Hazard (-1 to 4 Limited Approach
Flash Boundary
Incident Energy RestrictedApproach
(callcm) Prohibited Approach

(4) Protective Equipment ULeather Shoes

Safety Glasses/Goggles UEar Plugs TOVoltage-rated Shoes
U Natural Fiber Clothing Leather Gloves_
OFR Clothing DFace Shield UVoltage-rated Gloves U Hard Hat
UVoltage-rated Tools UBalaclava Hood TUOner
OFlashsuit
UCategory II Meter 2 Layer Switching Hood
Other
Means employed to restrict the
access of unqualified persons from
the work area
(5)
Authorized Workers wWID #
Authorized Workers wID#
(6)

ENERGIZED:
WORK WHILE ELECTRICALLY
TO PERFORM THE
PART II1: APPROVAL(S)

Authorized Person/ Engineer Date

Management Designee Date

PART IV: WORK discussion of any job-related hazards:

Evidence of completion of
Job Briefing including

(Worker signature) Completion notes

PART V: cOMPLETION_

Close-out Date
Authorized Person

Return to: HS&E Coordinator,

 APPENDIX 11C-WORK AT HEIGHT PERMIT
(THIS PERMIT MUST BE
Permit Number
DISPLA YED WHILE WORK IS IN PROGRESS)
Date: Site Name Check the box when Item has been completed.
an
Work by: Time: Pemit Shall not
u
Employee u
Supplier (Write name)
untli followlng precautlons have been checked. be issued
Ya N| Requirement
Start time
Location of work (exact): Completlon time Thefollowing hazards are assoclated with this work-
Descnption of work: U|U Falling Objects
Risk of Falling Persons
High Winds
Overhead Electric Cables
Unguarded Edges
Unsecured Ladders
Lack of Space
Special Precautions (describe
protective equipment to be
specific details, including persona Uneven Floor Surfaces
used): Manual Handling of Loads
an
Fragile Roots
Other hazards not listcd above

The work involves

the following-
Permit request prior ULadders
understand commencement Scaffolding
supervision fromthat
An
the area shall be continuously
start to
completion of the under
Excavatlon (falling below)
Lone Working
attendant shall be posted if job.
This attendant shall be additionallone person is working
to the
at helght. Ladders:
Site Supervisor's Name work site supervisor. Ladder inspected and found in good condition?
Secured and long
Attendant's Name: Signature: enough?
Base is mounted on good footing?
Ideclare that
the Signature If extended, then 2
rung overlap?
notes have been precautions on the right column and
verified to commence work and important Barrier at base of ladder and warning
sign in place?
supervisor (write name if different that a
work Access Scaffolding:
from requester):
has been communicated Scaffolding Inspected by: .
precautions. of such
DKick boards in place?
Hand rails in place?
Requester Name: UBarrier and warming signs in place?
ACceptance by authorized personI prior
Signature:
understand the Work at height to beto performed
commencement
and the
Working at Height:
necessary satety precautions to complete the work )ApprOximate height work will be carried out:
Outlined in this pemit, method safely as UAGK0rusn placer
assessments. If conditions statement and/or Hand raills in place?
the method change to the extent that this isk
permit,
my
statement and risk assessments become invalid, it is|
PPE:
responsibility
to stop work All required
PPE provided?
requester. The disposal of any immediately and notify the | | U | All PPE
residues of the hazardous inspected and observed to be in
materials Used will be in accordance with the good conditions.
regulations. applicable | Is there a specitic method statement
UD permit)
Is
required? (if yes, attach it to this
there a risk assessment
pemit)
performed for this job? if yes, attach it to this
Acceptor Name:
Signature:
Does the work involve
Approval signature indicates that any of the following? (Use appropriate permits
have completed the addition to this permit) in
precautions in the right column, followed the Important Notes
and pemission is therefore granted for this work. Hot Work Confined Space Entry []
Isolation (LOTO) [|
Others (Specify)
Approver Name Signature
Continuatlon of Work
hereby request the work specified in this permit to continue mportant Notes
until the time stated below,
having personally verified the safety 1. USE OF LADDERS
arangements and confim that they remain adequate. dersshould
Ihey should be in good condition
be long
Ladders should
enough for the work in hand
Permit has been extended be secured botn
to am/ pm If
extensions are used there shouldat the top and bottom
be at least wo
Sufhcient clearance must be rungs overlap
Requester Name Signature Joserve the 1 in 4 rules provided al the base of the ladder with barrners and
waming signs
Permit Cancellation adder lags shall be in place
This . USE OF STEP LADDERS
permit is cancelled. The work is not
complete. Safety
precautions have been removed. inges, iings and cords shoula be in good
not craCKed or conditian
I reads
snould be secure and
broken
Requester Name: sleps should be set corectly, level and secure,
Signature nsure that work can be completed sately withoutopen to full extent and adjusted to the correct angle
Completion of Work/ Final check over-reaching or standing or kneeling on the lop step or
declare that the work described above Sufncient clearance must be
is all workEnsure that excessive the provMded around the ladder with
equipment, persons and materials under my complete
control have been
work does not
barners and warning signs
require excesSive weight to carmed
le.
provided
sheets of wood
withdrawn. All safeguards have been Scaffolding must be erected by a or plaster board

area retumed to reinstated and the

safe status and service. also
a
work t must be competent person
protected against damage from trafic
I declare that the be
permit is ready to close, and I have recelvea
coples or the
Kick boards must be and any one inside the barrier must wear head
in-place to stop items from being pratection
from the Approver. permitHand rallstags
Scaffold a be ftted all points where there arisk
must at knocked oft the scaffoldina
af falu the
nisk of
inere is
is a Scaftolding
place falling through
.WORKING ATLin
Requester Name Signature Fall
HEIGHT
prevention measures should be used i e
Closure of Confined Space Entry Permit A Sareiy
Crawling narness
should be wom barrmers
wherever reasonably
boards must be used when
The area has been practical, where other controis are not
inspected and ali sarety
reinstated to their normal operating status. systenis nave
working on elevated surtaces empioyed
DEEl When warking alone, workers must have adequate
Approver Name communication or
adequate levels of supervision
|Signature
Rev. 01
 HOT WORK PERMIT
Permit Number:
Date Site Namne: Check the box when an item has been completed. Permit Shall not be issued
Work by: oEmployee o ime until following precautions have been checked.
Start time: Contractor (Write namne): Yes NA Requirement
Location of work (exact): Completion time: | s there a specific method statement required? (if yes, attach it to this
Description of work: permit)
0 Is there
permit)
a risk assessment performed for this job? if yes, attach it to this
General Precautions
Sprinklers and/or fire hose in service
Hot work equipment inspected and found in good condition
Special Precautions
protective equipment (describe
Area supervisor notified
specific details, including
to be
used): personal Area checked for presence of
flammable/ combustible vapors
Precautions within 35 ft (10.7 mts) of work
H Floors swept clean of combustibles
Combustible floors wet down, covered with
sheets damp sand, metal, or
fireproof
Permit request
understand thatprior
the commencement
All combustible materials or flammable
liquids preferably relocated,
ompletion of the job area
and
shall be monitored for 60 minutes
after
otherwise carefully covered with metal
Allwall and floor guards or flameproof curtains.
minutes. thoroughly inspected at the end of 60 openings covered
After the 60 minute Fireproof tarpaulins suspended beneath work to collect
be made for an period, additional pedestrians sparks and protect
Work ends). additional three hours intermittent patrols should Work on walls or ceiling
(four hours total after hot
Firewatch Name (60 min): Construction is noncombustible
covering/ insulation type and/or is without
Firewalch Name (3 hrs):
Signature: combustible
I declare that the Combustibles moved away or
notes have been verified precautions on the Signature
right column
and
wall/ ceiling adequately covered in the
opposite side of
work and thatimportant Work on enclosed equipment
to commence
supervisor (write a work
requester): name
different Equipment cleaned ofall combustibles
ot Such precautions from Containers purged of
has been communicated flammable vapors
Requester Name: Adequate air flow
welding is done through enclosed equipment is provided
Acceptance by authorized person Signature: Fire watch observer
while cutting/
Iunderstand
safety
the hot work to
be
prior to commencement Isavailable during and for
precautions to pertormed
cormplete the work sately as outlined and the
necessary hours for 60
minutes after
permit, method statement cold watch operation concluded and 3
change to the extent and/or risk
assessments. If
in this
IsIs equipped with extinguisher(s)
risk that this permit, the conditions and/or
equipped with appropriate Gas/ HC aware of fire hose location
assessments become method statement and Is trained in
work invalid, it is my use of detectors (if required)
immediately equipment and in sounding
requester. responsibility
and notity the to
residues of the
hazardous materials The disposal of stop alarms
with the used any Does the work
applicable will be in involve any of the
Approval regulations. accordance additionto this following? (Use appropriate
precautionssignature
in the rightindicates
column,
that Ihave
completed Confined Spacepermit)Entry permits in
permission is theretore granted forfollowed the Important Notes and the Others 1 (Specity):. Work at
height 1 Isolation (LOTO) | 1
Dprover Name: this work. In the
ontinuation of Work 1 Signature and use
event a fire
should occur, call
hereby the alarm box located (Phone):
the time request
the work
stated below, specified in this permit to continue until Important Notess
at
having
arrangements and confirm that theypersonally verified lame or spark-producing
Permit has been extended remain adequate. the safety equipment
maintained good properlyequipment
must be
to: used andto allbe used has been
Requester Name: am / pm 2. The condition.
ground
in

clanp (electric
cables/ gas hoses,inspected and found
valves,
in
good repair.
Permit Cancellation |Signature: could become
source ot
arc
welding) should be
regulators, torched and
Hot work
allachrnents
This permit is ignition. Ground clamp should
carefully connected, since,
precautions havecancelled.
3. Persons be an
The Work isS pertorming connected inproperly
hot work must to the work connected cianp
as close
not
Requester Name been removed. complete. qualifed individual be
Safety pr qualilied to
pertorrn
as
possible so that
hot nkiers
such tasks. The
ana re
Completion of Work/ Final Signature: work is
EQUIPMENT
suppression equipment
being done. NO are cornmission and
in
work should be
supervised
declare that the work check be
IS OUT HOT
maintained in a stateOFof SERVICE. FirewORK PERMITS SHALL will not be taken
by a
equipment, described above 5. There
extinguishing BE out of
service
persons and
withdrawm. All materials under
is
complete all
are no
contaning such
readiness for immediate
combustible fibers. equipnent suitableISSUED for
IF FIRE while this
SUPPRESSION
my control have work
use
dusts, potential hazards present
area returned tosateguards
a safe
have been
reinstated and the been
combustible gas materials
equipment, detection
have been vapors. gases or
purged. liquids in the area.
The absence
must
permit is ready to close status and service. I also work 6. The work wil tanks, this areainstrument.
or
is
1 there
is a
of
gases or
Tanks and
equiprent
and being of a leak vapors has been prevIOusly
be
from the Approver. I have
received copies declare tha the 7.
Surrounding contined to the area
floors have been
possibility
continuously monitored veritied by
Requester Name of the permit 8.
barrier.
or
equipment and personnel
swept clean developing
in
nearby piping
Flamable ard and, if
specified on this
Closure
The area hasHot Work Permit Signature
of precautons combustible material
such as should be
combustible, wet down
and/or covered permit.
been removed tron the using fire-resistant wih a tire
systems have beeninspected, free from risk and all
9. ho-work area, control tarps removed and/or retarding
10. Ample portabie shall be protected
Fire watch reinstated to their fire
Al
combustiblesextinguishing
have equipment, potential migration
taken to cover from the
hot-work.
retch Nameobsenvation
(60 mn):
protection
has finished (4 normal operating opposte sides of wals been
removeC shall be
such
if heatrelocated 35 teet
as hose
of
lines or
hot
sparks and slag to areas/equipment
other
Speaal
that canngt De
hours) status. 11. Ail can be (farther for elevated extinguisher, has been tloors/areas
rewatch Name (3 hs: loor and wall prot transferred work)
Approver Name Signature operings within 35 feet
to thern
provided.
through the work from the
operatign inciuding aeas
Signature watch ene
of the
cold nsork activty. Theek area operations
e hot worue hot-work operations have Combustibles
ha S or covers f
piece onbustibles th areas oon
that canriat on
Signature: hthe ch ends
intenvening
tor 60 mrave been tightiyo t ordinary ulins)
tighly covered k
thentervening threehe
or
it three hours or fire conditine Er is then to fnla dosed
i s narea is rciprotertot1 are needen ch 0r rest
penod ana he
 APPENDIX 11D - DEMOLITION WORK PERMIT
IN PROGRESS)
(THIS PERMIT MUST BE DISPLA YED WHILE WORK IS lssued until following
Check the box when an item has been completed. Permit Shall not be
|Permit Number: Site Name precautions have been checked.
Date: Time: Yes NIA
Work by: u Employee u Supplier (Vrite name) Requirement
Demolition Plan
Start time Completion time A demolition plan is available on site.
is available.
Locationofwork (exact): A method statement prepared by a professional engineer the
Description of work: The Supplier, Safety dept, Supervisor
and lor personnel directly involved in
demolition works would be carried out?
demolition works is conversant with how the
conducted for demolition works. Safe Work
A risk assessment has been proposed
Procedures indicated in the Risk Assessment has been implemented

Permit-to-Work
Special Precautions (describe specific details, including personal on site.
protective equipment to be used): A permit-to-work system has been implemented
A supervisor has been appointed for
the worksite.
a s s e s s o r has been appointed for the worksite.
A safety hazards and
work have been informed of the
All persons involved in demolition
Permit request prior commencement precautions they have to take.
understand that the area shall be continuously under and Catch Platforms
Hoarding, Covered Walkways barricaded. Measures to prevent unauth orized
supervision from start to completion of the job and all required is
The site hoarded or
adequately
displays/ wamings/ indications shall be maintained through out entry are implemented. Catch
of overhead protection a r e provided.
means
Covered walkways or other
the job execution period. wall or roofs are
are and maintained where exterior masonry
provided
Attendants shall always be posted at the boundaries of the platforms
being demolished.
Demolition site with continuous communication to control the Preparation for Demolition
be demolished have been
the exterior of the building to
pedestrian and vehicle movementin this area. All glass and cladding to
Area Monitor's Name: Signature: removed prior to c o m m e n c e m e n t of demolition
lines have been shut capped off and
AttendantS Name. All gas, electric, water, steam and other supply such
Signature or electric lines need
to be maintained during demolition,
ieclare that the precautions on the right column and important If power, water, gas
lines have been relocated or adequately protected
| notes have been verified to commence work and that a work
Open side / Openings
name different from fall more than 1.2 meters are
supervisor (write i where a person is liable to
has been communicated Open sides or openings other equally effective means
effective guardrails, barriers or
requester) covered or guarded by
ofsuch precautions. to prevent fall.
Signature Access and Egress
Requester Name: levels are provided
means of access and egress from different
Acceptance by authorized person prior to commencement Safe
understand the confined space entry to be performed and the Lighting are provided where persons are at work.
the work safely as Sufficient and
suitable lighting
necessay safety precautions to complete Presence of Asbestos
outlined in this pemit, method statement and/or nsk 1 | U asbestos
Checks are carried out determine
if materials to be handled contain
assessments. If conditions change to the extent that this pemit, Materials suspected to contain asbestos are sent for analysis
it is authorities (if required)
the method statement and risk assessments become invalid, a notification has been sent to
For works involving asbestos,
to
stop work immediately and notify the in advance of any such works
my responsibility
residues of the hazardous Noise
requester. The disposal of any Suitable hearing protectors are provided to all persons exposed to excessive noise.
the applicable
materials used will be in accordance with
Personal Protective Equipment
regulations. to persons at work which requires
Personal protective equipment is provided
foot protection, hand protection,
Signature: protection, including eye protection, fall protection,
Acceptor Name: head protection, hearing protection, respiratory protection

that have completed the Debris Accumulation of the

or external walls, or at any part
Approval signature indicates Debris, on the floors, against hoardings
followed the Important Notes and constitute a hazard
precautions in the right column, worksite should not be allowed to accumulate so as to

pemissionis therefore granted for this work. Debris Disposal enclosed

Approver Name: Signature Openings used for removal of debris, except the top or working floor, are
be
from tloor to ceiling. If an enclosure cannot be provided, effective barricades shall
Continuation of Work continue until provided at 6m from the openings.
specified in this pemit to the A warning notice indicating the hazard ot talling debris has been placed.
ereby request the work having personally venified safetyy Demolition of walls, other structure or part of a structure
time stated below,
remain adequate. Demolition of walls and partitions in a worksite shall proceed in a systematic
arrangements and confim that they
am/pm completed before the
Pemit has been extended to manner. All work above each tier of floor beams has been
Requester Name: Signature: removal of its supports
demolished are left in such a
No structure or part of structure which is being
inadvertently, or be weakened due to wind
Permit Cancellation condition that it may fall or collapse
cancelled. The work is not complete. Safety pressure, vibration or other causes
This permit is
precautions have been removed. Manual Demolition
use of hand tools, safe footings
in
Where any demolition work is carried out with the
Requester Name: Signature:
the form of sound flooring or scaffolds are provided for persons working on an
Final check exterior wall
Completion ofWork Where any demolition work is carried out with the use of
hand tools, there are no
I declare that the work
described above is complete all work walls or partitions that are left stand1ng more than 1 storey above the uppermost
matenals under my control have been
equipment, persons and U floor where persons are working
been reinstated and workthe I
withdrawn. All safeguards have Mechanical Demolition
area returned to a safe status nd service. I also declare that the Where a clamshell bucket is used, a zone of 8 metres of the line of travel of the
to close and I have received copies of the permit
pemit is
ready bucket is maintained.
for demolition work, an adequate zone
Where other mechanical appliances are used
fromthe Approver the
in the area to ensure safety of persons at work.
Requester Name Signature S maintained
Machines such as excavators and breakers shall descend down to the next floor by

Permit means ofa ramp. The ramp should take into consideration the loading imposed.
Closure of Confined Space Entry all have been there a specific method statement required? (if yes, attach it to this permit)
The area has been inspected and safety systems IsDoes the work involve any of the following? (Use appropriate permits In addiuon))
reinstatedto their nomal operating status.
Hot Work U Work at height [] Isolation (LOTO) [I
Approver Name: Signature
Others [ ] (Specify):
In the event an emergency, call (Phone)
and usethe alarm box located at

Rev. 01