WORK PERMIT

Valid only when signed by an authorized issuer, delegated by management. This permit must be issued before specified work is started; it must be
canceled immediately after completion of the work or at the end of the shift as agreed by parties identified on this permit. File canceled permits in
chronological order in a file, which will be stored in unit.
ISSUED TO:
NAME COMPANY/CONTRACTOR DESIGNATION

FOR WORK IN:

EQUIPMENT / LOCATION AREA

STARTS AT: Hrs. / / (Date) EXPIRES AT: Hrs. / / (Date)F

DESCRIPTION OF WORK TO BE DONE:

This certifies that I HAVE personally completed a safety inspection of the area where this work is to be done, as well as the surrounding area, with
specific attention to the type of work checked below. I HAVE reviewed the minimum precautions and have indicated on the reverse side of this
permit all necessary precautions taken to protect the personnel engaged in this work from accident and injury. I HAVE made sure that the assigned
personnel know the applicable safety rules and that they know what to do in an EMERGENCY.

Permit Issuer Name:

 HELD PRE-JOB DISCUSSION

Signed at Job Site by Date Time
RESPONSIBILITY ACCEPTED BY:

Engineer: Date:

Supervisor: Date:

The following type of works is covered by this HAZARDOUS WORK PERMIT:

 1. Potential exposure to hazardous atmospheres - All work where confined spaces are created (tanks, vessels etc.) during the construction phase,
will consider the hazards associated with entry into these areas.
 2. Hot work, Welding, Grinding or Cutting Operations in confined, overhead, process or any other construction area where precautions,
communications and fire watch may be required
 3. Manual Excavations and Trenching exceeding 4 ft in depth and all mechanical excavation, boring.
 4. Elevated and Overhead work - All work on scaffolds, temporary platforms, two legged ladders, tanks, and elevated positions in excess of 6 feet
(1.8m) above floor level.
 5. Crane lifts and critical rigging (Above 85% of load chart)
 6. Radiation (X-rays)
 7. Suspended work basket / Platform
8. Working on or around pressurized or energized systems / Pneumatic Testing
 9. Electrical Work
 10. LOTO
 11. Commissioning activities
 12. OTHER:

HAZARDOUS WORK PERMIT CLOSURE

 WORK SATISFACTORILY COMPLETED, housekeeping is restored to normal

 HWP AREA AND EQUIPMENT RELEASED IN PROPER CONDITION FOR NORMAL USE
 WORK NOT FINISHED, to be continued with a new work permit issued by another competent person.
 WORK SUSPENDED, as present conditions are not conductive for carrying the work safely
Cancelled at job site by: Date: Time:
 PRECAUTIONS TAKEN AND EQUIPMENT PROVIDED TO PROTECT PERSONNEL FROM ACCIDENT OR INJURY.
(Multiple categories may apply to any given job)
Check items completed prior to start.

1. Potential Exposure to Hazardous Atmospheres ( Confined Space) 5. Crane Lifts & Critical Rigging. Contractor procedure in place: YES NO
(Oxygen deficiency or enrichment, dust, toxic gas, and vapors) Precautions Taken
Contractor procedure in place: YES NO  Crane / Slings inspected before use
PERMIT REQUIRED SPACE: YES NO , If Yes STOP  Operator qualified by the contractor
Precautions Taken  Electrical power line clearance (12ft) checked
 All valves and equipment locked and tagged  Ground condition inspected
 Safety Observer Assigned
 Blinds  Block and Bleed  Piping Separation  Path cleared for material movement
 Guy rope, rigger available
 Process lines purged  Ventilation provided  Mechanical   Specific Requirements:
Natural Draft
 Atmosphere tested (O2, H2, CH4, etc.) See Table Below. 6. Radiation (X-rays) Contractor procedure in place: YES NO
Attendant / Rescuer Precautions Taken
Equipment Provided  Source control & duration on site part of work sequence planning
 Work schedules considered the minimum potential exposures to site personnel
 Respirator SCBA  Neg. Pressure  Supplied Air  Competent qualified personnel assigned for tasks
 Lifeline  Two-way communication device   Barricades and warning signs are in place and obvious
Emergency Alarm  Special Clothing  Specific Requirements:
 Hood  Dust Goggles
 Other (explain) 7. Suspended work basket / Platform Contractor procedure in place: YES NO
Precautions Taken
 Approved by competent personnel
2. Hot Work (Welding, Grinding, Cutting) (For any hot work , monitor  Lifelines and harnesses approved type with separate anchorage
for flammable and oxygen enriched atmosphere and record above)  Two-way communication established
Contractor procedure in place: YES NO  Specific Requirements:
Precautions Taken
 Flammables / Combustibles (paper, rags, wood, etc.) protected or 8. Working Around Pressurized or Energized Systems / Pneumatic Testing
removed Contractor procedure in place: YES NO
 Fire Watch Established Precautions Taken
 Welding & Cutting equipment Safe to use and positioned properly Is work to be performed planned: YES NO , If No - STOP
 Leads up and do not pose a tripping hazard  Access/egress, Hot work, Other on-going work considered in plan
 Area hazards covered  Specific hazards in the work area identified
 Specific  Area cleared of non-test personnel and barricaded
Requirements:  Discharge of safety relief valves directed away from personnel area
 Formal discussions with personnel performing work or affected by this work held
 Specific Requirements:
Fire Protection
Precautions Taken 9. Electrical Work Contractor procedure in place: YES NO
 Area wet down Precautions Taken
 Spark shields installed LIVE ELECTRICAL WORK PERFORMED BY QUALIFIED ELECRTRICIAN ONLY
 Spark resistant tools  LOTO done
 Area and its adjacent cleared off and barricaded  Circuit checked for zero voltage
 Work spot has proper access  Portable cords and electric tools inspected
Specific  Safety back-up man appointed
Requirements:  Area and its cleared off and area barricaded
Equipment Provided Equipment Provided
PPE  Approved rubber and leather gloves  Insulating mat  Fuse puller
recommended:  Disconnect pole or safety rope  Non-conductive hard hat
 Fire bucket  Earth Leakage Circuit Breaker ( ELCB )  Flash protective clothing
 Fire extinguishers  Specific Requirements:
Type:  CO2  Dry Powder  Other
10. Lockout / Tag out ( LOTO) Contractor procedure in place: YES NO
3. Excavations Exceeding 1.2 m ( 4 ft ) Contractor procedure in
Precautions Taken: Type of power supply  Hydraulic  Pneumatic  Steam
place: YES NO
 Mechanical  Electrical  Other
Precautions Taken
 Contractor has a competent person assigned to inspect & control  All valves locked and tagged
condition of excavation on site  Blinds installed
 Block and bleed valves positioned
 Underground utilities identified
 Barricades, flashers, pennants (area warning) placed  Piping separated
 Means of egress (ladder or steps) in place  Pressure bled from lines and equipment
 Area and its adjacent cleared off and barricaded  Instrument gas disconnected
 Material or soil removed from excavation edge  Attempt to start the equipment
 Specific  Mechanical energy blocked
 Maintenance lock / contractor lock required
Requirements:
4. Elevated / Height Work Contractor procedure in place: YES
NO 11. Commissioning Activities
Precautions Taken  All commissioning work is scheduled, approved and coordinated through Unit Manager. 
 Ladder(s) inspected prior to use and is secured. Work Plan includes available
 Scaffolds/platforms inspected for good repair  Work area laid out
 Work area roped off and warning signs in place  LOTO done
 Proper access available from near by areas  Specified hazards identified
 Area cleared below and adjacent areas prior to starting work  Other on-going work cleared off the area
 Area barricaded  Required Personal Protective Equipment available with workers
Equipment Provided  Identification of energized or pressurized systems
 Full Body Safety Harness and Lanyard anchored to independent rigid  Fire protection equipment, location and accessibility
object
 Lifeline with rope grab shock absorber 12. Others:
 Safety Net
 Specific
Requirements: