I have attached a rule and regulation manual where the permit conditions are mentioned.
| GENERAL WORK PERMIT | Permit SR.No. | ||||||||||
| To be filled in by Job Supervisor/ Engineer | |||||||||||
| Permit Valid from …………….. To …………., if Job supervisor changed then their signature should be incorporated in the format | |||||||||||
| Job Executor | Name: | Sig.: | Date: | Time: | Department: | ||||||
| Description of work | |||||||||||
| Equipment No | |||||||||||
| Location | |||||||||||
| A | Action Taken by Executor : Please write Yes or No in the box provided. | ||||||||||
| Sr.No. | Hazard Identification | Yes/No | Remarks | ||||||||
| 1 | Electrical | ||||||||||
| 2 | Confined area | ||||||||||
| 3 | Height Work | ||||||||||
| 4 | Hot Work | ||||||||||
| 5 | Excavation work | ||||||||||
| 6 | Mobile Crane | ||||||||||
| 7 | Compressed Air | ||||||||||
| 8 | Hydraulics | ||||||||||
| 9 | Any Other | ||||||||||
| B | PPE Required : Please write Yes or No in the box provided. | ||||||||||
| Sr.No. | PPE | Yes / No | Sr.No. | PPE | Yes / No | ||||||
| 1 | Full Body Harness | 5 | Hand Gloves | ||||||||
| 2 | Ear Plug | 6 | Apron & Leg Guard | ||||||||
| 3 | Goggle / Face shield | 7 | Heat Resistance suit | ||||||||
| 4 | Dust Mask | 8 | Any Other | ||||||||
| C | Permits Required : Please write Yes or No in the box provided. | ||||||||||
| Sr.No. | Safety Checks for compliance | Yes/No | If Yes, Permit No. | Remarks | |||||||
| 1 | Is Electrical Work Permit Required ? | ||||||||||
| 2 | Is Confined area permit required ? | ||||||||||
| 3 | Is Height Work Permit Required ? | ||||||||||
| 4 | Is Hot Work Permit Required ? | ||||||||||
| 5 | Is Excavation work permit required ? | ||||||||||
| 6 | Is Process Isolation required ? If YES, take clearance form process Dept. |
Name of Concerned Process Engineer | Signature & Date | ||||||||
| Permit Issuer | Name | Signature | Date | Time | |||||||
| Concerned Engineer | |||||||||||
| Concerned SH | |||||||||||
| Acceptance: | To be completed by the person who will carry out the job. Then to be handed back to issuing person. | ||||||||||
| I understand the work which is to be carried out and the method of work to be used to ensure that it is carried out safely . | Signature: Date: Time: (Job Supervisor/Contractor ) |
||||||||||
| No work will be carried out other than the work authorized by this permit | |||||||||||
| Extension / Transfer of permit | All checks reviewed & found OK to extend permit | Remarks | |||||||||
| Date | Signature | Date | Signature | Date | Signature | Date | Signature | Date | Signature | ||
| Job Supervisor | |||||||||||
| Concerned Engr. | |||||||||||
| Concerned SH | |||||||||||
| Completion: | The above work is completed. Man power deployed is removed from the working site. | Signature: Date: Time: (Job Supervisor/Contractor ) |
|||||||||
| Note : | 1. This permit Applies only to work in the location described. | ||||||||||
| 2. This permit only applies to the person to whom it is issued. If work has to be continued by someone else, this permit must be returned to issuer for cancellation and another permit issued. | |||||||||||
| Copy :(1) Job Sup./Contractor (2) Safety Office, (3) Office Record ( Retention Period 7 days) | |||||||||||
Click Here To Download General Work Permit
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