PDS HSE Templates - Permits

Project Name: Project's Name

Project Manager:
Site Manager:
Project Address:

Documents contained in this workbook:

General Work Permit Confined Space Entry Permit
Height Work Permit Mobile Crane Pre-Start Checklist
Hot Work Permit Blasting Activity Permit
Demolition Permit Night Work Permit
Penetration Permit Excavation Work Permit
 General Work Permit

Project Name: Project's Name Permit No.:

Contractor Name: Date:
Location:
Nature of Work: Validity from: Hrs to Hrs
(Trade/s)
Description of works to be executed:

Prior to issue permit, the following points to be ensured:

The work area must be inspected prior to issue work permit. Yes No NA
(1) Work Area is free from any obstruction / hazards?
(2) Sufficient lighting arrangement provided?
(3) Scaffold / Ladder Inspected?
(4) Energy Source Isolated / Disconnected If Any?
(5) Electrical power supply, ELCB, Earthing and connection Checked?
(6) Fire extinguisher provided for Hot Works?
(7) Is the area cordon off / barricaded with display of Signage?
(8) Equipment / Tools Inspected and tagged?
(9) Safety Signage’s are in Place?
(10) Is Personal protective equipment provided and being used?
(11) Job briefing to all crew members?
Any special instructions that must be complied with -

Personal Protective Equipment: Hard Hat, Safety Shoes & Reflective Vest is Mandatory and Job Specific PPE’s to be worn as per
requirement.
Name of the Permit Holder: Designation: Signature:

To be filled by the Permit Issuer: (Any specific precautionary measures proposed while carrying out activity)

Permitted to Carry Out Work With Above Safety Precautions:

Name of the Permit Issuer: Designation: Signature:

Closure of Work Permit:

Name of the Permit Holder: Designation: Signature:

Document Name: Version: Correct as at: Page No.:

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 Note: For Height Work, Hot Work, Excavation & Confined space a separate work permit to be followed. Permit is Valid for 8 Hours/ One
shift. If the work extended, then separate permit to be obtained. Permit to be displayed at site.

Document Name: Version: Correct as at: Page No.:

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 Height Work Permit
Project Name: Project's Name Date:
Contractor's Name: Trade:
Supervisor's Name: 2nd:
Names and Licence
Numbers of Workers
seeking access:

Scope of Work to be Permit valid from: am/pm

performed at height: Permit valid to: am/pm

DESCRIPTION OF RISK YES NO COMMENTS & ACTIONS

P P
Scaffolding
Is the condition of the scaffold acceptable as per JLL and the relevant local
standards for scaffold?
Has proper access been provided?
Are platforms of sufficient width, secure and complete?
Is comprehensive edge protection in place – handrail, mid-rail, toe-board?
(mesh / safety net where applicable?)
Are suitable baseplates provided?
Are High Voltage clearances maintained?
Are outriggers in place? (where required)
Are wheel locks present and in working order?
Roof Access
Has an assessment of weather conditions been conducted to assess suitability
for working at height?
Have workers received a Work Activity Induction, including reading and signing
their SWMS?
Has the roof area been inspected for structural strength?
Is there safe and suitable access to work areas?
Are workers protected from falling from edges?
Are workers protected from falling from incomplete structures?
Are workers protected from falling through skylights and penetrations?
Are people protected from the dangers of falling objects?
Is electrical supply available at roof level?
Has a rescue plan been developed for use in the event of an arrested fall?
Do workers have appropriate UV protection?
Plant & Electrical Equipment
Has all equipment been listed in the relevant register and fitness certificate/tag
provided as per local legislation?
Have servicing requirements been met?
Are all guards in place?
Has electrical equipment been tested and tagged?
Are electrical leads clear from metal scaffold?
Is power being sourced from the same level/floor?
Is RCD/ELCB (mechanical) protection in place?

Document Name: Version: Correct as at: Page No.:

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 Height Work Permit
DESCRIPTION OF RISK YES NO COMMENTS & ACTIONS
P P
Personal Protective Equipment
Is all relevant PPE available and serviceable?
Do harnesses, belts, ropes etc. have current log books / inspected?

References (include available and/or surrogate local regulatory references OR DELETE):

XXXX Scaffolding
XXXX Code for Fixed Platforms, Walkways, Stairways and Ladders
XXXX Industrial Safety Belts and Harnesses – Selection, Use and Maintenance
XXXX Self-Locking Safety Anchorages for Industrial Use
XXXX Safety Signs for the Occupational Environment
XXXX Eye Protectors for Industrial Applications
XXXX Respiratory Protective Devices
XXXX Sunscreen Products – Evaluation and Classification
Please add as appropriate

Comments:

SIGNED: (Contractor Supervisor) DATE:

Approval for Work at Height: Granted / Declined

SIGNED: (JLL PDS Representative) DATE:

IF DECLINED, ACTION REQUIRED BY SUBCONTRACTOR WITH AGREED TIME LINE:

ACTION COMPLETED - APPROVAL GRANTED

SIGNED: DATE:

Procedure:

1. A separate permit has to be completed for each and every height work activity.
2. Maximum approval period is one day / one shift.

Document Name: Version: Correct as at: Page No.:

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 3. This work permit must be completed by the work supervisor and then be reviewed & signed by a JLL representative.

Note: - A copy of this work permit must be posted at the work place adjacent where the work is being conducted.

Document Name: Version: Correct as at: Page No.:

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 Hot Work Permit

This completed Hot Work Permit is to be hanging adjacent to the work being conducted and a copy attached to the relevant SWMS.
Project Name: Project's Name Location of Hot Work:
Permit No.: Date & Time:
Task to be Completed:
Heat generating equipment used:
Fire protection equipment required:
Personal protective equipment required:
Prior to issuing this permit, the following questions must be considered and answered:
The precautions ticked below must be fully observed. Yes NA
1. Have all combustible materials been removed from the work area or made safe? (Within 15 metres)
2. Are appropriate fire extinguishers located within 2 metres of ignition source?
3. Is ventilation, Illumination adequate?
4. Will sparks be contained completely; are flash screens available to be used?
5. Have welding machine/gas cylinders been inspected, including for spark arrestors?
6. Is the welding machine earthed directly to the equipment, has supply amperage been checked?
7. Pipe work or other vessels decommissioned and vapours flushed?
8. Trolley is being used for the Gas cylinders?
9. Have all drains, pits and depressions been checked, isolated and sealed?
10. Is the body of the welding machine is connected with earthing?
11. Is the area cordoned off with the Caution Tape & with HOT WORK Signage
12. Is Personal protective equipment available and being used?
List special conditions that must be complied with? (Refer SWMS)

PERSON REQUESTING AUTHORISATION - CONTRACTOR REPRESENTATIVE (Site Eng. / Supervisor)

I have read and fully understand the precautions listed in the SWMS attached to this permit.

Name & Signature: Date:

CONTRACTOR AUTHORISED COMPETENT PERSON ALONG WITH JLL REPRESENTATIVE

The hot work can be carried out safely provided that the precautions listed in the SWMS are adhered to

Name & Signature: Date:

Name & Signature: Date:

PERMIT VALID from am/pm to am/pm Date:

TASK COMPLETED: Works have been completed and area checked for smoking embers.

Signature: Date: Time: am/pm

Note: The work cannot be allowed, if the permit is not signed from Authorised person and is valid for one shift, i.e. 8 hrs. If the work extends beyond the shift,
another permit required to be generated.

Document Name: Version: Correct as at: Page No.:

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 Demolition Permit
Project Name: Project's Name Permit Number:

Project Address: Location of Work:

Contractor Name: Contractor Number:

Permit Valid: From Date: Time:

To Date: Time:

Prior to Demolition, the following must be considered and signed off:

All Isolations or Disconnections must be completed as per company SWMS.
Yes NA
1. Has the Asbestos Register been consulted?

Have the following been considered: Access and egress, site security, exclusion zones and spotters, noisy works permits from local authority?

JLL Authorised Representative:

Name & Signature: Date:

2. Has Building Management approved of the demolition?

JLL Authorised Representative:

Name & Signature: Date:

3. Have Electrical services been isolated or disconnected?

Contractor to provide an electrical clearance certificate.

Electrical Representative:
Company:

Name & Signature: Date:

4. Have Mechanical services been isolated or disconnected?

Contractor to supply a checklist of isolated or disconnected services.

Mechanical Representative:
Company:

Name & Signature: Date:

5. Has Structural Engineer Approval been consulted or obtained?

JLL Authorised Representative:

Document Name: Version: Correct as at: Page No.:

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 Name & Signature: Date:

Document Name: Version: Correct as at: Page No.:

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 Demolition Permit
Yes NA
6. Have Fire services been isolated or disconnected?
Fire Representative:
Company:

Name & Signature: Date:

7. Have Hydraulic services been isolated or disconnected?

Contractor to provide checklist.

Hydraulic Representative:
Company:

Name & Signature: Date:

8. Have all Hazards been identified in the Demolition SWMS.

Contractor to provide SWMS/JSA.

Demolition Representative:
Company:

Name & Signature: Date:

9. Can Demolition commence?

DEMOLITION CONTRACTOR WITH JLL AUTHORISED REPRESENTATIVE
Demolition can be carried out safely provided that the precautions listed in the SWMS are adhered to.

Name & Signature: Date:

Name & Signature: Date:

Additional Comments:

PERMIT VALID from am/pm to am/pm Date:

TASK COMPLETED:

Signature: Date: Time: am/pm

Note: The work cannot be allowed if the permit is not signed from all authorised representatives, and is valid for one shift (i.e. 8 hours). If the
work extends beyond the shift, another permit is required to be generated.

Document Name: Version: Correct as at: Page No.:

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 Penetration Permit
Project Name: Project's Name Permit Number:

Project Address: Location of Work:

Contractor Name: Contractor Number:

Permit Valid: From Date: Time:

To Date: Time:

Prior to any penetration work, the following must be considered and signed off:
All Isolations or Disconnections must be completed as per company SWMS.
Yes NA
1. Has a structural and electrical slab scan been completed?

The structural and electrcial slab scan report to be attached to this document.

Contractor involved:
Company:

Name & Signature: Date:

2. Has the task been approved by an engineer to proceed?

Contractor to provide evidence that an engineer has signed off on the penetration to proceed.

Contractor involved:
Company:

Name & Signature: Date:

3. Has Building Management approved of the penetration?

JLL Authorised Representative:

Name & Signature: Date:

4. Have Electrical services been isolated or disconnected?

Contractor to provide an electrical clearance certificate.

Electrical Representative:
Company:

Name & Signature: Date:

Document Name: Version: Correct as at: Page No.:

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Document Name: Version: Correct as at: Page No.:
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 Penetration Permit
Yes NA
5. Has the contractor reviewed the JSA with the workers?

Contractor to provide evidence of the review.

Contractor involved:
Company:

Name & Signature: Date:

6. Has all equipment been tested and tagged, and the Electrical Register been completed?
JLL Authorised Representative:

Name & Signature: Date:

7. Has a safe work area surrounding the penetration been established?

Contractor to provide a spotter and checklist of what has been established.

JLL Authorised Representative:

Name & Signature: Date:

8. Correct Personal Protective Equipment is in use by the contractor?

Contractors are observing PPE requirements as identified in the contractors SWMS/JSA.

JLL Authorised Representative:

Name & Signature: Date:

Additional Comments:

PERMIT VALID from am/pm to am/pm Date:

TASK COMPLETED:

Signature: Date: Time: am/pm

Note: The work cannot be allowed if the permit is not signed from all authorised representatives, and is valid for one shift (i.e. 8 hours). If the
work extends beyond the shift, another permit is required to be generated.

Document Name: Version: Correct as at: Page No.:

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 Confined Space Entry Permit
This completed Confined Space Entry Permit is to be hanging adjacent to the work being conducted and a copy attached to the relevant SWMS.

In accordance with XXXXX <INSERT LOCAL CODE> 5. VENTILATION

1. (a) Location of the work: Ventilation of the confined space has been achieved by:

(b) Contractor undertaking the work: Signed by Competent Person (sub-contractor)

6. PERSONAL PROTECTIVE EQUIPMENT
(c) Name of competent person doing the work: The following personal protective equipment ticked below shall be worn:

(d) Qualification(s) of competent person: Supplied air respirators

Air purifying respiratory devices
Safety bell, harness and/or safety line or rescue line
2. (a) Description of Work to be undertaken Eye protection
Hand protection
Feet protection
(b) Initiator of Request: Protective clothing
Date of Request: Hearing protectors
(c) Entry Date & Time: Safety helmets
(d) Hazards and controls are to be detailed in the SWMS.
Signed by Competent Person (sub-contractor)

THE WHOLE OF THE REMAINING DETAIL OF THIS PERMIT MUST BE 7. USE OF CHEMICAL AGENTS (Details to be completed)
AUTHORISED BEFORE WORK IS TO PROCEED AND ONLY WORK No chemical agents other than those listed below may be taken into the
LISTED MAY BE DONE. confined space:
(a)
3. ISOLATION OF CONFINED SPACE (b)
(a) Pipelines (Water, Steam, Gas etc.) (c)
(b) Mechanical/Electrical drives (d)
(c) Sludges/Deposits/Waste
(d) Harmful materials Signed by Competent Person (sub-contractor)
(e) Electrical services 8. HOT WORK
(f) Warning notices, locks or tags have been Hot work permitted – Yes / No
fixed to means of isolation
If hot work is authorised to be carried out within the confined space, a
Signed by Competent Person (sub-contractor) separate Hot Works Permit is required.
4. ATMOSPHERIC TEST REQUIREMENTS Signed by Competent Person (sub-contractor)
The atmosphere has been tested to ensure no oxygen 9. STANDBY PERSONNEL AND RESCUE ARRANGEMENTS
deficiency or excess and for the following contaminants. (Fill in
details and results of tests) (a) Standby persons are: (identity)
(a) (Oxygen)
(b) ( )
(c) ( ) (b) Rescue and emergency procedures are understood and all
equipment is in place.
(d) ( )
Continuing monitoring of the atmosphere is/is not required
(Delete as appropriate) Signed by Competent Person (sub-contractor)
The conditions are safe for entry under the conditions ticked
below:
(i) With a supplied-air respiratory protective device.
(ii) With an air purifying (non-air-supplied) respiratory
protective device.
(iii) Without a respiratory protective device.

Document Name: Version: Correct as at: Page No.:

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 Testing Time Date

Signed by Competent Person (sub-contractor) Continued overleaf.

Confined Space Entry Permit

This completed Confined Space Entry Permit is to be hanging adjacent to the work being conducted and a copy attached to the relevant SWMS.

10. OTHER PRECAUTIONS 12. SIGNING OUT

Precautions ticked below have been implemented: All persons have left confined space and further entry should not be
(a) Warning notices/barricades are in position permitted unless a new entry permit is signed.
(b) Smoking has been precluded in confined space
(c) Special precautions (indicate) Signed by Competent Person (sub-contractor)

13. WORK COMPLETED / SUSPENDED

(d) The SWMS is complete and attached to this permit All persons/equipment have been withdrawn, the work has been completed
and any plant/machinery is/is not fit for use. (Delete as appropriate)
(e) XXX Certificates for those entering the confined space
have been cited and are current (photocopy attached to
SWMS).
Signed by Competent Person (sub-contractor)
Signed by Competent Person (sub-contractor) 14. ACCEPTANCE OF COMPLETED JOB
11. AUTHORISATION (To be completed)
I accept the work as defined in Section 2 of this permit has been completed.
(a) The confined space described above is in my opinion in a
safe condition for the work to be done, provided that the
precautions above are fully observed
Signed by Competent Person (sub-contractor)

Competent Person Time & Date Signed by Site Management (principal contractor)
Valid Until Time & Date

Reference Material – Subcontractors are advised to obtain a copy of the <LOCAL REGULATION/CODE> regarding ‘Safe Working in a Confined Space’ to assist them in
their risk assessment, developing their procedures (including SWMS) and completing this form.

Document Name: Version: Correct as at: Page No.:

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 Mobile Crane Pre-Start Checklist

Project Name: Project's Name

Contractor Name:

ITEM PRIOR TO ARRIVAL AT SITE YES NO REFERENCE, COMMENTS

A   & ACTIONS
1 Have the crane company conducted a site visit and carried out a Risk
Assessment?
2 Has the weather forecast been checked for clear weather?
3 Has the cut-off time for cancellation been set so as not to incur full cost in
case of bad weather?
4 Is the lift scheduled for out of hours/when there are less contractors on
site?
5 Does the lift clash with public events?
6 Do bus services need to be redirected?
7 Has approval and permits been obtained from Council?
8
Has an alternate date been considered and approved by council?
9 Have street plans been obtained for underground services?
10
Are there any obstructions in the lifting zone? (power lines, trees etc)
11
Is a structural engineer’s report required / obtained for crane set up area?
12 Is the landing area / zone large enough for all material?
13 Is a structural engineer’s report required / obtained for landing area?
(slab / roof)
14 Is a Traffic Control Plan required / developed?
15 Has an environmental management plan been developed and
preventative measures recommended?
16 Have neighbours / local businesses been notified?
17 Is a dilapidation report required for set up area? (Damage to trees,
footpath, road etc.)
18 Has the crane company provided a lifting schedule?
19 Does the crane contractor’s SWMS detail the heaviest object to be
lifted / how many objects are to be lifted?
Crane contractor is: Accepted / Not Accepted for use on the project.

SIGNED: DATE: _____/_____/_____

ITEM ON ARRIVAL AT SITE YES NO REFERENCE, COMMENTS & ACTIONS
B  
1 Does the crane have full service history records available?
2 Are the crane log books up to date?
3 Are the crane operator and dog-man licenced?
4 Is lifting gear (ropes, slings, cages, etc.) tagged and up to date?
5 Have you carried out a visual inspection of lifting gear?
6 Have all contractors been site inducted?
7 Have all contractors read and signed their SWMS?
8 Do all contractors have PPE as indicated on their SWMS?
9 Are the correct barriers / signage in place? (Eg. Detour )
10 Are the correct environmental protection measures in place?

Crane is: Accepted / Not Accepted to commence work on the project.

SIGNED: DATE: _____/_____/_____

IF NOT ACCEPTED, ACTION REQUIRED BY CONTRACTOR WITH AGREED TIME LINE

Document Name: Version: Correct as at: Page No.:

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Document Name: Version: Correct as at: Page No.:
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 Blasting Activity Permit

A. Activity details

Name of the Site: Project's Name No. of the Blasts:

Date: Name of the Licensed

Blaster / Shot Firer:
Contractor Name:
Starting Time of Drilling
Location of Blasting: Operation:

B. Permit Validity

Permit Valid: From Date: Time:

To Date: Time:

C. Check Points before Blasting

Item No Description Yes / No

1. Have the detonators been checked individually for continuity and resistance?

2. Do all the detonators belong to the same manufacturer?

3. Are the explosives and cartridges selected for use the correct size?

4. Are the explosives and detonators of approved quality?

5. Have the condition of lead / leg wires been checked?

6. Are sockets in the blasted area flushed with air and water, and plugged?

7. Have the bore holes been cleared of all the debris before explosives are inserted?

8. Have all the excessive cartridges been removed from the work spot?

Have all persons involved in the operation come out of the spot after loading and
9.
been counted?
Have the environmental conditions been considered?
10.
(Rain / Sunny / Wind / Thunders / Lightning)

11. Are Electronic Items / Radios, mobile phones & pagers prohibited in the location?

12. Is the danger zone suitably cordoned with flagmen posted at important points?

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 13. Are suitable warning boards displayed at site?

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 Blasting Activity Permit

Item No Description Yes / No

14. Have the number of entry points been identified and access control is established?

15. Is the blaster’s shelter available and in good condition?

Has a proper signaling system been established to prevent trespassers entering the
16.
blasting zone, siren or hooter and made available?

17. Are all the drillers provided with Ear Plugs, Helmets, Goggles & Gum Boots?

Has a record been maintained in a separate register indicating:

• Date & Time of Blast; • Amount of Charge Per Hole;
18.
• Number of Holes; • Firing Pattern & Sequence; and
• Type of Explosive Used?
Mention the:
• Quantity of explosive brought from magazine.
19.
• Quantity of explosive used.
• Quantity of explosives returned to magazine.

Are any Electrical / Telecom line or cables near by?

20.
If so specify the distance & Voltage.

Has the circuit been checked?

21.
Specify the resistance.

I have checked the above points & found conditions suitable to undertake the blast.

Name and Designation of the Permittee:

Signature:

D. To completed up by the Issuing Authority

The precautions & safe conditions mentioned above have been verified & blast can be done.

People shall be evacuated from danger zone & warning sirens shall be blown before the blast.

Name and Signature of Issuing Authority:

Document Name: Version: Correct as at: Page No.:
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 Section In-Charge

Blasting Activity Permit

E. Check Points After Blasting

Item No Description Yes / No

Have any misfires been detected?
If yes, give the number of holes:

Brief of action taken:

1.

Has the “All clear” siren been blown? If yes, specify the time of the “All clear” siren.
2.
Time:

Name and Designation of the Permittee:

Signature:

Name and Signature of Issuing Authority:

Section In-Charge

F. To be completed by the HSE position-holder

Time: Date: at which the permit closed.

Name of HSE: Signature of HSE:

Document Name: Version: Correct as at: Page No.:

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 Night Work Permit

Project Name: Project's Name

Contractor Name: Trade Package:
Permit No.: Date: Location:
Permit Required From Time: To Time:
Adequate Illumination Provided: YES / NO Emergency Vehicle Available: YES / NO First Aid Box Available: YES / NO
Drivers Name & Ph. No.: Vehicle No.:
Activities scheduled for night & description of work being carried out:

Name of the Worker ID Number Name of the Worker ID Number

Reason for conducting these activities at night:

Name of the Permit Holder: Designation: Signature:

To be filled by the Issuing Authority: (Specific Precautionary Measures proposed while carrying out the activity if Any)

Authorised to work at night with the above mentioned safety precautions.

Name of the Issuing Authority: Designation: Signature:

Closing of the Permit:

Name of the Issuing Authority: Designation: Signature:

Document Name: Version: Correct as at: Page No.:

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 Note: Working at Height, HOT work to be follow separate work permit. Permit is Valid for One Night. Permit to be displayed.

Document Name: Version: Correct as at: Page No.:

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Excavation Work Permit

Project's Name
A copy of work permit to be displayed at job location with relevement attachments.
Project Name: Date:
Contractor Name: Trade:
Supervisor's Name: 2nd:
Excavation work details:
Permit Valid from: am/pm
Permit Valid to: am/pm

Hazards associated with work: Por O NA Por O NA

Vehicle / Mechineries Movement Overhead Power Lines / Utilites
Underground Utilites Uneven Surfaces
Manual Handling Falling Objects / Debris
Lack of Space Hazardous Atmosphere

DESCRIPTION OF RISK YES NA REMARKS

Adjacent areas inspected and protective measures are in place.

Nearby loose rocks or any other materials that may roll or fall into excavation.
Spoils, materials, and equipment set back at least 1.5mtr away from edge of excavation.
Does excavation area is barricaded.
Flagman provided to control unauthorised movement in that area.
Does underground utilities are identified and marked.
Protection from overhead utilities such as power lines, pipes etc are in place.
Does area is having any harmful / contamination / combustible exposure.
Oxygen level checked
Safe Work Method Statement (SWMS) is reviewed and available.
Slop / Shoring / Benching / is marked on the drawing and available at work location
Plant and Equipment's inspected & verified for the job and are in good condition.

Does the work involve any of the following? Yes / No - (Use appropriate permits in addition)
Hot Work Work at height Isolation (LOTO) Confined Space
In case of any emergency, call (Phone): __________________________
PERMIT HOLDER - ( Site Eng. / Supervisor)
I have read and fully understand the precautions listed in the SWMS attached to this permit,

Name & Signature: _________________________________________________ Date: _____/_____/_______

PERMIT ISSUER -
I have checked and verified the above and permitting to carry out the work :

Name & Signature: _________________________________________________ Date: _____/_____/_______

Name & Signature: _________________________________________________ Date: _____/_____/_______

WORK COMPLETION: Works completed and area inspected.

Permit Holder Signature: ______________________ Date: ___/___/___ Time: _______ am/pm
Permit Holder Signature: ______________________ Date: ___/___/___ Time: _______ am/pm
Note: The work permit to be signed by authorized persons. The permit is valid for one day / shift, i.e. 8hrs. If the work extends beyond the shift or day, another work
permit to be obtained.

Document Name: Version: Correct as at: Page No.:

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