NORTH-WEST POWER GENERATION FORM NO: NW-DH-QHSE-PTW-F-001

COMPANY LIMITED Effective Date: 07/09/2022

Permit to Work Revision No: 01
[Operation] Page 2 of 2
PART- 3 [OPERATION]: PERMIT TO WORK PTWR: Issue Date:
Related Special Work:  Yes  No Type: CSE  HW  W@H  Lifting  Radiography  Shutdown
Issued to: Contact No.: Planned date:to
Job(s) listed below is/are permitted to perform with this Allotted Working Periods Acknowledgement
PTW: From To EHS
Date Maint. (if any SCE
Hrs. Hrs. SPTW)

*Refer for safety instruction in the foot note of page 1

LOTO Box No: Isolation Date: Normalization Date:
Blocked
Name/KKS Position Before Isolated Done by Checked by Normalized Done by Checked by
S/N SEQ SEQ Status
Isolation Position (Opn) (Maint.) Position (Opn) (Opn)

1.
2.
3.
4.
5.
Extra Isolation Sheet Required : Yes  No
Issued only for Isolation By SCE Ensured by (Opn) Released By SCE[Activated] I understand and accept my
responsibilities for this PTW (Maint.)

Signature with date Signature with date Signature with date Signature with date
PART- 4 [MAINTENANCE] : CLEARANCE  Completion  Suspension Date: Time: Hrs.
Work done details:

Instruction to operation: I certify that all persons working under this PTW have Work Completed (Acknowledged
been withdrawn from the specified area and warned not to by HOD (Maintenance):
continue work / test. All equipment, tools, loose materials
and drain earths are removed, guards and access doors
refitted.

Signature with date(Returned by Maint. Assignee) Signature with date

Equipment Tested by: (O& M) Normalized By (Opn) Checked by (Opn) PTW Cancelled By SCE

(Operation)(Maintenance) Signature with date Signature with date Signature with date
Comments by SCE: Process closed by HOD (Opn)
 NORTH-WEST POWER GENERATION DOC No: NW-DH-QHSE-PTW-F-001
COMPANY LIMITED Effective Date: 07/09/2022
Permit to Work Revision No: 01
[Operation] Page 1 of 2

PART- 1: NOTIFICATION OF FAULT FNR: Date:

Notified By: Dept. Operation Others Contact No:

Urgency Level: Immediate/ASAP/ Minor/ Next Outage/ Monitor Only/ Info. KKS:

Area /System/Equipment:
Fault Details: Referred to Dept. of EMD MMD I&C CMD Others

Suspected Cause:

Action taken by Operation:

F/N Issued By SCE F/N Received By HOD Fault Validated by (Maint.)  Valid & Accepted  Not Valid & Returned

F/N found
Warranty Claim Referred to Other Dept.
(W/C)

Comments if Return:

PART- 2 [MAINTENANCE] :WORK REQUEST WRR: Date:

Assigned to: Contact No.: Isolation Required:  Yes  No
Maintenance Type: Corrective Preventive SPTW:  Yes  No Type: CSE HW W@HLift. Radio.
Support Required from other  Yes  No EMD MMD I&C CMD EHS Others
Description of Jobs to be Done:

*Please attach your Job Description / WI / Standard Maintenance Procedure

Personnel Available:  Yes  No  Planned Planned duration
AVAILABILITY & PLANNING
Spares Available:  Yes  No  Planned 
Tools Available:  Yes  No  Booked ___________ to ___________
Booked
Comments (Reason for Wait /Postpone/etc.): W/R Issued By HOD

Safety Instruction:
 Proper PPE should be maintained.
 Potable Fire Extinguisher must be kept near for Hot Works
 LOTO Procedure must be followed.
 All type of Safeties must be ensured during the work(s).
 Maximum Validity of a PTW is 7 Working Days. New PTW is required to continue work after this
duration. After each day PTW must return to SCE@CCR. Extension is required on each day before
resuming work.
 Operational personnel shall perform the Isolation with assistance of maintenance personnel. If any
assistance for isolation is required from other maintenance department (Not the executing dept.)
operation shall coordinate with them to ensure proper isolation.
 SPTW may required to be normalized before normalization of operational isolation.
 Maintenance and operation personnel shall sign in acknowledge form before start the work during
the PTW validity periods.
 Use separate isolation normalization form if isolation equipment’s are more than five.