SCAFFOLD ERECTION / MODIFICATION / DISMANTLING Form No.

PERMIT (FOR ALL HEIGHT) Permit No.

Area Regn No.
(Tick Wherever applicable)
Sign.
Panipat Refinery & (IN DUPLICATE) Name
Petrochemical Complex Date

To be filled by PERMITTEE
From ______________ Hrs. of Date ____________________To ______________Hrs. of Date _____________________________
Department ________________Section ____________Contractor __________________ Work Order No. ___________________
Exact Location of Work (Unit / Area / Equipment No. etc.) _________________________________________________________
Purpose of Scaffolding ______________________________________________________________________________________

CONFIRMATION BY PERMITTEE
Tick ( ) whichever is applicable

1. Type of Scaffold to be erected: Tube & Coupler / Cup Lock / Fixed tower / Cantilever / Suspended / Hanging
2. Maximum Number of persons allowed on Scaffold after Erection: ________ Nos.
3. Maximum Load on scaffolding after erection including tools & eqpt: ________Kg (Light duty / Medium duty / Heavy
Duty )
4. Maximum Height of Scaffold: _______ Meters; Base of Scaffold:________ Meters
5. Scaffold materials are in good condition & without defects & Free from rust, oil, cracks: Yes / No
6. Trained/Certified Scaffolder & Supervisor Shall be engaged for erection /dismantling of scaffold: Yes / No
7. Medical Fitness Certificate available with scaffolders: Yes / No

FOLLOWING ITEMS SHALL BE CHECKED BY PERMITTEE BEFORE SOLICITING THE PERMIT

Tick ( ) whichever is applicable

SN Points Yes No
1 Work site inspected & found base /surface consolidated / hardened (Sole board to be used, in case of loose soil)
2 Scaffold materials properly stacked at site, without obstructing approach routes
3 Full Body Safety harness with double hook lanyards available & in good condition
4 Fall arrester / safety net available at site & in good condition
5 Standard Aluminium Ladder of adequate length & in healthy condition available at site
6 Warning signs / barricading tapes available at site
7 Proper clamps shall be used for securing working platform planks & Ladder
8 Red Tag shall be provided while erection / modification /dismantling of scaffold
9 TOOL BOX TALK shall be given on daily basis & Record to be maintained

FOLLOWING ITEMS SHALL BE CHECKED BY ISSUER BEFORE ISSUING THE PERMIT

SN Points Yes No
1 Work area inspected, Surrounding area checked, cleaned and covered.
2 Gas Test: ______% LEL; ______________ppm (toxic gas) _________ % Oxygen
3 Proper Ventilation & Lighting provided
Following relevant hazards & precaution communicated to concerned personnel & Record maintained:
1.
4
2.
3.
Note A: Following PPEs to be used in addition to standard PPEs (Safety Helmet, Safety Shoes, Hand Gloves, Boiler Suit & Full
Body Harness). Tick ( ) whichever is applicable
Safety Gas Responders
Ear Muff / Plug Dust Respirator Safety Net
Goggles (Specify)
 Horizontal Retractable Fall
Vertical Life Line Rope Grab Fall Arrestor Airline
Life Line Arrestor
Others, if Any

Note C: Additional Precaution, If Any ___________________________________________________________________________

Sign: Sign:
Name: Name:
Designation: Designation:
ISSUER PERMITTEE

SHIFT WISE CLEARANCE RENEWAL IS MUST WITHOUT WHICH THE PERMIT WILL BE INVALID:
Time Gas Test
Date Additional Precaution Issuer Permittee
From To (HC/ Toxic / O2)
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_
HC_____Toxic_____O2_____
_

CLOSING of PERMIT

PERMITTEE : Certified that the subject work has been ISSUER: Verified that the job has been completed and
Completed/ Stopped & Area Cleared area cleared and is safe from any hazard.
Date & Date &
Name Designation Sign Name Designation Sign
Time Time

IMPORTANT INSTRUCTIONS:

1. No Separate Work at Height Permit to be obtained along with this permit, however, once the scaffold is erected,
permit for working at height along with Job specific permit (Hot/Cold work) shall be taken as per existing permit in
SAP.
2. The permit shall be issued in duplicate. Original copy will be issued to the Permittee and Duplicate copy shall be
retained by Issuer.
3. The permit shall be valid for Maximum Seven (7) days subjected to Shift wise clearance.
4. This permit must be available at work site at all times.
5. The work permit shall be filled up carefully and accurately in clear handwriting ensuring that complete information
is provided in all sections/subsections.
6. Appropriate safe guard and required Personnel Protective Equipment (PPEs) shall be determined by a careful
analysis of the Potential Hazards.
7. Job shall be stopped / discontinued during rain/ high wind/ adverse weather conditions.
8. On completion of the work, the permit shall be closed and returned to the issuer.
9. In case of Fire Siren, job must be stopped and concerned personnel must leave the work site and proceed to
designated assembly Point.
10. Railings and toe boards shall be provided on the platform.
11. The top rail shall be at height of 900-1200 mm and mid rails must be installed approximately halfway between the
top rail and the platform surface. Toe boards (150mm) should be securely attached to the working platform. Toe
boards are generally applicable to working platform and not for landing platforms.
12. During erection, the ladder shall be installed as early as practicable, but not later than first two horizontal members
(Ledgers). This is to facilitate Scaffolder while erecting the scaffold.
13. Scaffolds shall be designed to support at least 4 times the anticipated weight of Men, material and wind force.
14. Make certain that all scaffolds are in plumb and levelled condition at all times.
15. Scaffolds must be constructed at least 3 planks wide unless location makes this physically impossible.
16. Landing platform should be provided at every 9 meter of height or less.
17. The members of scaffolds should extend at least 6" on either ends but not more than 12". They should be fastened
on both ends and laid tight by clamps.
18. All scaffoldings having height to base ratio more than 4 shall be secured firmly with permanent structure in X and Y
direction at least every 6 meters.
19. Scaffold which spread to 20 meter or more should have two accesses preferably from opposite side.
20. Red Tag indicates “Not fit to use” scaffold & No job other than erection/ dismantling shall be carried out on Red
Tagged scaffold.
21. Green Tag Indicates “Fit for use” scaffolds & job can be performed on Green Tagged scaffold.
22. Keep distance of at least 150mm between high temp Pipelines or equipment and scaffolding.
23. Safe distance from overhead electrical lines to be maintained as per Site electrical safety procedures.
24. Scaffold shall be erected away from excavated area.
25. Members of scaffolds should not obstruct any access / pathways.
26. No wires should be used for fastening working platform planks and ladders.
27. Scaffolds should be revalidated on green tag at frequency not exceeding 7 days or after every modification /
alteration / whenever the scaffold is exposed to adverse weather condition such as high wind, heavy rain etc.

SCAFFOLD LOAD CHART

Load duty Light Duty Medium Duty Heavy Duty
Type of Scaffolding Maximum Safe load
75 150 225 300 450 600
in Kg/m2
Tube & Coupler Max. bay length
2.7 2.2 1.8 1.4 1.0 0.8
Scaffold (distance between
two verticals) in
Cup Lock Scaffold 2.5 2.0 1.5 1.25 1.0 NA
Meter