HEALTH, SAFETY & ENVIRONMENT PLAN

Working at Height Permit

Permit no : Date:
Project :
Location :
Job description:
Contractor :
A. Safety Precautions:-
S. No. Description Yes /
No
Scaffolding:

1 Scaffoldings of good construction ,adequate with 600 mm width walkways,

toeboards
2 Scaffold secured with stairways, wide enough to pass 2 persons at a time, hand
rails,(should be of metal scaffolding)
3 Maintain good housekeeping at work locations

Safety nets:

1 Safety nets fixed at the bottom of scaffold to prevent bodily injuries in case of fall

Ladders:

1 Strong materials used and well maintained

2 Ladder not placed against loose boxes, round materials. objects, near electrical
installation
3 Ladder of sufficient height used, on top tied and positioned at the foot of ladder

4 Safety foot ware provided at base

5 Ladder placed at an angle of 70 -75 degrees

6 Area of the work barricaded so that no person can walk under the ladder

Personal Protective Equipment:

1 Safety harness provided and worn

2 Life line to be provided for anchoring harness where applicable

B. Permit Initiation & Issue

Details Name Signature, Date & Time
Declaration of initiator /Contractor:
a. All the above safety precautions have been put in place, based on Job safety analysis
as per method statement and verified by me on ground personally.
b. I shall ensure all the necessary precautions, till end of the work & I shall take full
responsibility in case of any deviations or lapses noticed on site.
 HEALTH, SAFETY & ENVIRONMENT PLAN

Permit Initiator/contractor

Permit Initiator/Contractor
(Contractor PM / Engineer)

Checked & Confirmed By

(Contractor Safety Officer)
Comments by M MOSER:
Permit is issued based on work progress schedule & on the above
declaration from the contractor. In case of any NC noticed by M MOSER/
consultant/client during site rounds, necessary actions as per
Contract/Statutory conditions shall be taken.

M MOSER Project Team

C. Permit Closure:

The above-mentioned job has been completed satisfactorily. Date…………………………………. & Time
……………………………… this permit is closed.

Details Name Signature, Date & Time

The work has been completed and can be closed

Permit Initiator
(Contractor PM / Engineer)
Checked & Confirmed By
(Contractor Safety Officer)
Comments by M MOSER if
any

M MOSER Project team