PERMIT-TO-WORK (PTW) SYSTEM

NIGHT WORK PERMIT

NIGHT PERMIT NO COMPANY: MANPOWER: START DATE:
REGULAR WORK PERMITS NUMBER FINISH DATE:
LOCATION:
Section A: SAFE WORK PLAN

Authorized Person: Position: Phone#:

Description of the work:

S/N HAZARDS PRECUATIONS

Section B: HAZADS IDENTIFICATION (Tick Where Appropriate)

Y N N/A Is sufficient illumination provided? Y N N/A Is there an ambulance and nurse present?

Y N N/A Are additional permits needed? Y N N/A Is the required safety coverage provided?

Are all employees equipped with clear safety

Y N N/A Is Security notified of the night work? Y N N/A
glasses?
OTHER CONCERNS:

Section C: Acceptance: I accept responsibility for the work/personnel started. Agree to implement safe working
procedures and confirm that all personnel are adequately trained and will work only on the job/equipment specified.
TASK SUPERVISOR/FOREMAN (PERMIT HOLDER) SITE ENGINEER (PERMIT ISSUER)

NAME: MOBILE # NAME: MOBILE #

SIGNATURE: DATE: SIGNATURE: DATE:

APPROVED BY:
WORK PERMIT MANAGER AREA SAFETY REPRESENTATIVE

NAME: MOBILE # NAME: MOBILE #

SIGNATURE: DATE: SIGNATURE: DATE:

NOTE: (1) This permit must be submitted to the NESMA SAFETY DEPT. before Start the work. (2) The copy of work permit must be
placed at the work location. (3) Fail to comply safety requirement, the work shall be stopped. (4) If work is required on elevated areas
Elevated Work Permit shall be taken. (5) Attachments:
IF ALARM IS SOUNDED, THIS PERMIT IS CANCELLED