Height Work Permit
Project Name: Permit No: HTWP/
Contractor's Name: Date: _______/________ /20_____
Supervisor's Name: am / pm
Permit Valid From:
Numbers of Workers Going to be engaged in the job: am / pm
Job to be performed at height: Location of Height Work:
DESCRIPTION OF RISK YES NO COMMENTS & ACTIONS
Scaffolding
Scaffold installed in accordance to standard and acceptable to work?
Has Safe access been provided?
Are working platforms of sufficient width, secure and complete?
Is the edge protection in place - handrail, mid-rail, toe-board?
Is the safety net in is applicable and provided ?
Are suitable baseplates provided?
Are High Voltage clearances maintained?
Are outriggers in place in the required locations.
Are wheel locks present and in working order?
Is the safe tag provided ?
Roof Access
Weather condition is analyzed to assess suitability for working at height?
Have workers received job specific Induction & Training?
Has the roof area been inspected for structural strength?
Is there safe and suitable access provided 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?
Is the fall arrester system provided to arrest fall?
Do workers aware on the safe way to execute the job?
Plant & Electrical Equipment
All equipment's fitness certified and tagging done as per standard?
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/RCCB (mechanical) protection in place?
Personnel Protective Equipment
Is all relevant PPE available and in good Condition.
Do the shock absolver harness, guard ropes, fall back arrester found safe for use ?
CONTRACTOR AUTHORISED PERSON (Site Eng./ Supervisor) - (PERMIT GENERATOR)
Requesting and confirming by contractor's representative: I confirm that the precautions specified above is complied with and the persons carrying
out the work are fully briefed on the safe method of work as defined in the JSA.
Signature &
Name
Date
APL ENGINEER IN CHARGE - (PERMIT ISSUER)
Permission
Confirmation: I understand and certify that the precautions are adopted for height work according to Granted Declined
above check points and approved JSA for the activity.
Signature &
Name
Date
1. This completed Work Permit is to be displayed at the work location and along with approved JSA.
Note: 2. The work cannot be allowed, if the permit is not signed from authorized person.
3. Each work permit will be valid for a single shift and may be renewed for subsequent shifts.
