Title Page
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C&W Services LOTO Authorization Permit
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Permit #:
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel Involved
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Location Description:
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Task Description:
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Description of Machine/Equipment/System
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List of Authorized Employee(s):
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List Of Affected Employee (s):
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Permit Preparer's name:
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Types Of Energy
- Electrical
- Mechanical
- Hydraulic
- Pneumatic
- Chemical
- Thermal
- Other Energy
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Other Energy Types:
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Magnitude Of Energy
- 110VAC
- 220VAC
- 480VAC
- 277VAC
- Other
- Slight Mechanical
- Moderate Mechanical
- High Mechanical
- Slight Hydraulic
- Moderate Hydraulic
- High Hydraulic
- Slight Pneumatic
- Moderate Pneumatic
- High Pneumatic
- Slight Chemical
- Moderate Chemical
- High Chemical
- Slight Thermal
- Moderate Thermal
- High Thermal
- Other
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Other Magnitudes:
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Hazards of Energy
- Shock
- Fire
- Explosion
- Caught in/on/between
- Pinch Points
- Striking by/against
- Inhalation
- Skin Contact
- Absorption
- Heat Stress
- Cold Stress
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Other Hazards Of Energy:
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HAS YOUR ENERGY ISOLATION DEVICE BEEN INSTALLED? Click To Confirm.
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What type of energy isolation device was used?
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Other Energy Isolation Device(s)
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What is the location of your Isolation Device?
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What is your control Method?
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WAP APPROVAL DATE/TIME
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WAP Approval - I hereby approve this LOTO Work Permit and attest the equipment has been de-energized. The service/maintenance task (s) may now proceed. This permit is valid for the time required to perform the task, or 1 work shift or 8 hours from the time of signature (whichever is less).
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I verify all LOTO devices have been removed.
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I verify that all equipment has been returned to normal operating conditions.
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I have notified all affected personnel that the system is back in service.
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I have ensured that work is completed and accepted.
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Alternate Option:
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WAP CLOSURE DATE/TIME
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WAP Closure
