WORK PERMIT

WORK PERMIT
PROJECT NAME: PROJECT NO.:
DATE: WORK PERMIT NO.:

1. WORK PERMIT INFORMATION

Description of Work: ___________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
Exact Work Location: ___________________________________________________________________________________________________________________________________________________________________

2. PERMIT RECEIVER'S INFORMATION

Contractor (Company Name): ________________________________________________________ Contractor (Company Contact Nos.):
Contractor (Company Address): ______________________________________________________ Telephone: ___________________________________________
Contractor (Employee Name): _______________________________________________________ Email Address: _______________________________________

3. SUPPLEMENTARY PERMIT REQUIRED

Excavation Permit Gas Test Certificate Electrical Work Permit

Hot Work Permit Confine Space Entry Permit JHA and Methodology

4. WORK PERMIT VALIDATION

Applicable Date Specified: Applicable Time Specified
From: _______________________________ To: _______________________________ From: _________________________________ To: ____________________________
Date Date Time Time

5. MANPOWER REQUIREMENT
Contractor (Employee Name Assigned): Name of Assigned Workers:
_______________________________________________1. ___________________________________________4. __________________________________ 7. ____________________________________________________
_______________________________________________ 2. ___________________________________________5. __________________________________ 8. ____________________________________________________
3. ___________________________________________6. __________________________________ 9. ____________________________________________________

6. TOOLS AND EQUIPMENTS TO BE USED (With valid Safety Inspection Sticker)

Safety Inspection Sticker No.: _____________________ Tools & Equipment to be used:
1. ______________________________________________________________3. ______________________________________________________________________
2. ______________________________________________________________4. ______________________________________________________________________

7. SAFETY PRECAUTIONS

SAFETY PPE REQUIRED SAFETY EQUIPMENT WORKPLACE SAFETY PRECAUTIONS

Hard hat with chin strap Fire Extinguisher Fire Watch
Safety shoes/Boots Fire Hose and Water Drum Fire Blanket
Safety glass with side shield Ladders Safety Signs
Safety belt and Lifeline Flashback Arrestors Detour Signs
Ear plugs or ear muffs Check Valve Traffic Warnings
Dust Mask Emergency Torch Tape barriers
Gas Mask (specified) Mancage Temporary Railings
Hand Gloves Manbasket Shore protection
Face Shields Ropegrab (specified) Others
Cutting goggles Gas tester
Welding Mask First Aid Kit
Long Sleeves and Leggings Others
Others

8. AUTORIZATION & ISSUE

PERMIT ISSUER PERMIT RECEIVER NOTIFICATION
Contractor (Employee Name): Safety Dept. Rep.:

_______________________________________________________ ___________________________________________________________ __________________________________

(Signature Over Printed Name) (Signature Over Printed Name) (Signature Over Printed Name)

Date/Time: ____________________________________________________________Date/Time: __________________________________________________________ Date/Time: ____________________________________

(I have reviewed the conditions as outlined in this permit and I examined the ( I accept the conditions specified above of this permit). (I have validated and notfied the above person responsible of

work permit zone. The necessary safety precaution have been undertaken, the different important safety precaution,therefore I endorese

and therefore I authorized the work to proceed). the work to proceed.)

9. COMPLETION AND CANCELLATION

____ The work has been completed. All the isolations removed and the worksite has been left in safe condition.
____ The work has been suspended and will continue at a future date. All isolated permits will remain active.
____ The permit has been cancelled. All copies of this permit has been confiscated or destroyed.
PERMIT ISSUER PERMIT RECEIVER NOTIFICATION
Contractor (Employee Name): Safety Dept. Rep.:

_______________________________________________________ _____________________________________________________ ________________________________

(Signature Over Printed Name) (Signature Over Printed Name) (Signature Over Printed Name)

Date/Time: ____________________________________________________________Date/Time: __________________________________________________________ Date/Time: ____________________________________

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