Prepared by: HSE Engr.

TEMPORARY ELECTRICAL WORK- FORM - 34 Reviewed by: PM

Approved by: MD
Page 1 of 1

Permit No: Date:

ISSUED TO ___________________________ EQUIPMENT NO. __________________________

COMPANY ___________________________ LOCATION __________________________
DATE ISSUED ___________________________ TIME ISSUED __________________________
DESCRIPTION OF WORK TO BE DONE ___________________________________________________________
________________________________________________________________________________

ANSWER WITH X WHERE APPLICABLE YES NO NA Remarks

1. Live Work Required
2. Remote Control Isolated
3. Lock-Out and Tag-Out in Place
4. Warning Signs and Barricades Erected
5. Connected to Ground / Earth
6. Suitable Access/Egress Provided/Available
7. Personal Protective Equipment Required
8. Other Hazards, Specify
9. Emergency Procedures and Contacts available

THE EQUIPMENT AND/OR LOCATION WHERE THE WORK IS TO BE DONE HAS BEEN INSPECTED AND WORK IS SAFE TO DO

SIGNATURE OF AUTHORIZED PERSON ______________________

DATE _________________ TIME____________
NOTE: THIS WORK PERMIT TO BE ALLOCATED A NUMBER AND ENTERED INTO CONTROL LOG MAINTAINED BY RESPONSIBLE PERSON

ASSOCIATED WORK PERMITS HOT COLD CONFINED SPACE ENTRY

SPECIAL INSTRUCTIONS TO BE FOLLOWED

_______________________________________________________

_______________________________________________________________________________________

I UNDERSTAND THE HAZARDS INVOLVED IN THE ABOVE PERMITTED WORK AND THE PRECAUTION REQUIRED HAVE BEEN EXPLAINED TO ME

SIGNATURE OF COMPETENT PERSON ______________________

DATE _________________ TIME _____________

CLOSE OUT
I HEREBY DECLARE THAT THE WORK IS COMPLETED, ALL WORKERS UNDER MY CONTROL HAVE BEEN WITHDRAWN, AND WARNED
THAT IT IS NO LONGER SAFE TO WORK ON THE APPARATUS SPECIFIED IN THIS PERMIT, AND THAT ALL TOOLS, TEMPORARY EARTHING
CONNECTIONS HAVE BEEN REMOVED, AND THE SITE RESTORED TO A SAFE AND TIDY CONDITION.

SIGNATURE OF COMPETENT PERSON ______________________

DATE _________________ TIME _____________

CANCELLATION
I I ACCEPT THAT THE WORK IS COMPLETED/SUSPENDED, AND THAT THE SITE IS RESTORED TO A SAFE AND TIDY CONDITION, AND THAT THE
APPARATUS IS READY FOR COMMISSIONING

SIGNATURE OF AUTHORIZED PERSON ______________________ DATE _________________

TIME____________

NOTE: SHOULD CONDITIONS CHANGE OR EMERGENCY ALARM SOUNDED – WORK MUST STOP IMMEDIATELY

IN THE EVENT OF AN EMERGENCY CONTACT SITE HSE OFFICE ON XXXXXXX