PERMIT TYPE: PERMIT No.

STATION:
1.
Job Originator:……………………… Validity Unit:
Dept:…………………………………….. From Date:
Signature……………………………….. To Date: Equipment No:

Job Description
…………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………….

2. Hazard Identification and Special precaution

Hazards Special Precautions

Gas Equipt movement 1. …………………………………………………………………………..
Height Chemical 2. ……………………………………………………………………………
Ignition pressure test 3. ……………………………………………………………………………
Depth Others: 4. …………………………………………………………………………...
Confined space 5. .…………………………………………………………………………...
Heat
Electrical

3. Protective Equipment, Loss prevention and Certificates

a. Personal Protective Equipment b. Safety and Loss prevention c. Isolation Certificates
Safe belt Extinguisher Confined space
Helmet/Boot Gas Test Mechanical
Ear protection Fire watch Electrical
Breathing protection scaffold/ladder Excavation
Eye goggle Sparks arrestor Radiography
Facemask Lighting JSA
Gloves Warning sign Method statement/Procedure
d. Required gas test
□ Oxygen Level …………………% SWL:19.5-21.3%
□ Flammable Gas…………………% LEL
□ Toxic Gas……………………..ppm

I have carried out the gas test and am certified that the worksite it is safe and all tests are within acceptable level to continue
work
* Gas Tester Name………………………………(HSE) Date…………………………… Signature…………………………….
Time……………………………..

4. Approval by Worksite Supervisor (O&M)

I have examined the work description, preparation and precaution stated above. I agree they are correct.
Name……………………….. Signature………………………………………

From Time…………………. Date…………………. To Time…………………………. Date…………………

5. Authorization By Area Authority (EPCC)

I have inspected worksite and am satisfied that it has been properly prepared for the work specified on this permit

Name………………………………. Signature…………………………………..

Site inspection time……………………………. Date…………………………………...

 6. Authorization By Area Authority (EPCC)

I have inspected worksite and am satisfied that it has been properly prepared for the work specified on this permit

Name………………………………. Signature…………………………………..

Site inspection time……………………………. Date…………………………………...

7. Revalidation
a. Acceptance by worksite supervisor b. Re-Authorization by Asset holder c. Worksite
Suspension

I have inspected the

Name………………………… Signature……………….
I have inspected the worksite and am satisfied
that it is safe to continue work.
Name………………………… Signature………………… worksite. It has been left in
a clear and safe.
I am satisfied that the worksite is safe for the
work specified and I have re-authorized the Name..…………………..
permit for the period stated. Signature……………………….

Name Dept. Responsible Signat Valid from Valid until Signature Time Date Signatur
from ure e

time Date Time Date Time Date

8. Permit Cancellation-Work complete 9. Permit Cancellation-Work Not Complete

a. Permit Return by Worksite Supervisor. a. Permit Return by Worksite Supervisor.

Work complete, Worksite and equipment affected left in safe Work not complete, Worksite and equipment affected left in safe
condition. condition

Name: ……………………………………. Time:……………………………………. Name:…………………………………… Time:…………………………………..

Signature:……………………………… Date:……………………………………. Signature:……………………………… Date:……………………………………..

b. Permit Cancellation by Area Authority b. Permit Cancellation by Area Authority

Delete as appropriate.
Work not complete, Worksite clear and safe
Work complete, worksite clear and safe. Work continuing on permit No.:
Re-Instatement/De-Isolation complete Re-Instatements/De-Isolations complete.

Name;…………………………….. Time…………………………….. Name;…………………………….. Time……………………………..

Signature………………………………… Date…………………………. Signature………………………………… Date………………………….