Permit to Work Form

Complete Parts A , C and D, Complete relevant Part B

PART A
Date: HLG Subcontractor : ______________________________ Permit No. R/A No
Time of
Location: Level: Permit Holder: Start: Finish:
Work:
This permit is issued to the named permit holder and is not transferable. The permit is valid for one shift only.

Check the box ( ) for the Type of Work to be Performed and Attach short description of work activity.
Erection/ Dismantling of Scaffold Excavation
Working in Confined Space Hot Works
Working In Shaft/ Risers Energising/Isolating (Electrical Circuits)
Removal of Penetration Covering/ Barricade/ Edge
Working in Cradle/ Mast Climber/ Manbasket
Protection
Other (Specify:_____________________________) Other (Specify:______________________________)
Check the box ( ) for the hazards that are adequately controlled as identified in the Risk Assessment
Oxygen Deficiency/ Nitrogen Vehicles Manual Handling Slip or Trip
Chemical Dust/ Mist/ Fumes Restricted Areas Work at Height
Flammable High Pressure Excavation Other______________
Vibration Electrical Mechanical or Pinch Other______________
Noise Heat Moving Object Other______________

PART B
Erection/ Dismantling of Scaffold – HLG/HSE/SPI/00320 Excavations – HLG/HSE/SPI/00315
Yes N/A Yes N/A
Risk Assessment attached Toolbox talks given Risk Assessment attached Toolbox talks given
Area barricaded & inspected by SO completing
All tools attached to the body with lanyard
permit
Lifeline available Area CAT scanned and utilities marked
Workers with full body harness and dual lanyard Supervisor Available
Supervisor available All plant maintained
Area barricaded & inspected by SO completing
Drivers trained
permit
Watchman & barricade below the work area to avoid
MAS 00246 available and applied.
unauthorized entry
Working in Confined Space – HLG/HSE/SPI/00301 Hot Works – HLG/HSE/SPI/00305
Yes N/A Yes N/A
Risk Assessment attached Toolbox talks given Risk Assessment attached Toolbox talks given
Adequate mechanical ventilation (i.e. fans, exhaust) Walkways/ area protected beneath hot work.
Combustible materials removed Hot work equipment in good condition
Emergency equipment available/ accessible Welding Screens
Confined space and emergency training for entrants
Fire Blankets
and watcher
Gas test completed by competent person with
Appropriate signs available
satisfactory result
Lighting arrangement Exclusion zone/ barricade work area
Suitable PPE Suitable fire extinguisher available
Suitable/ adequate access and egress Competent worker
Type of adjacent works considered Fire observer/s available
All opening secured in an open position MAS 00244 available and applied
All pipelines, electrical sources isolated
Energising/ Isolating (Electrical Circuits) -
Working in Shaft/ Risers- HLG/HSE/MAS/00233
HLG/HSE/SPI/00298

BICC/HSE/SPI/FM/00989 Rev 01
 Permit to Work Form | Page 2 of 3

Yes N/A Yes N/A

Risk Assessment attached Toolbox talks given
Workers with full body harness and dual lanyard
Supervisor available
Working platform in good condition and certified
Overheard protection available
Exclusion Zone below work area
Working in Cradle/ Mast Climber/ Manbasket –
HLG/HSE/SPI/00309
Yes N/A
Risk Assessment attached Toolbox talks given
Supervisor/Foreman Available
3rd party certificate of cradle and operator is valid
Independent lifeline is installed
All workers with full body harness and lanyard
attached with grabber clamp
Daily inspection of cradle/mast climber
completed/recorded
Fire extinguisher(s) available in the cradle
All tools are attached to the body with lanyard
Watchman & barricade below the work area to avoid
unauthorized entry
Signage in place as per MAS 00242
Other _____________________________________________
Yes N/A
Risk Assessment attached Toolbox talks given
LOTO SPI available and followed
Competent Electrician
Supervisor Available
Removal of Penetration Covering/ Barricade/ Edge
Protection – HLG/HSE/SPI/00299
Yes N/A
Risk Assessment attached Toolbox talks given
Area blow the penetration barricaded off
Barricade provided/area cordoned off
Control measures in place to prevent material
falling
Full body harness in use and adequate
anchoring point available
Signage in place as per MAS 00234
Other _____________________________________________
Yes N/A

PART C
PERMIT TO WORK AUTHORIZATION & ISSUANCE
I have reviewed the details
PTW Issuer Date/Time: Signature:
of this permit.
I have checked the work
PTW Holder Date/Time: area and the work activity Signature:
is safe to commence.

PERMIT TO WORK CLOSEOUT - WORK COMPLETED

I confirm the work area Signature:
Permit holder Date/Time: has been checked and in a
safe condition.
Permit filed for record Signature:
PTW issuer Date/Time:
purposes.

PART D

HLG/HSE/SPI/FM/00989 Rev 00
 Permit to Work Form | Page 3 of 3

SIGN ON
I fully understand all of the hazards of this job and all of the conditions I must follow to ensure the safety of myself and my co-
workers.

Code #/
Name Position Time In Signature Time out Signature
Company

HLG/HSE/SPI/FM/00989 Rev 00