Culligan Electrical Work Permit

• Date Work is taking place? (Permit is valid for 24hrs).

  Date

• Prepared by

• What is the task? (Brief description of the work taking place)

• What is the name of the contractor?

• Is the contractor performing the task approved on the supplier database?

  Yes

  No

• Address issue with purchasing department

  Select Issue addressed with purchasing department

  • Issue addressed with purchasing department

• Name of the site workgroup manager/supervisor.

• What is the site workgroup manager/supervisor's telephone number

• Are all members of the workgroup site inducted?

  Yes

  No

• Perform Contractor induction and retain evidence.

  Complete

• Are the electrician(s) NICEIC or similar qualified? Have all work related licenses and skills cards been witnessed, in date and evidence taken?

  Yes

  No

• What evidence do they have to show they are competent to perform the task?

• Risk Assessment/Method Statement received and approved

  Yes

  No

• Review risk assessment and ensure all precautions stated are in place before work commences

  Complete

Significant Hazards and Control Measures . (See Risk Assessment and Method Statement for full details)

• Are you using extension leads?

  Yes

  No

• If using any extension leads, you MUST not overload any units, have extensions fed from extensions (Daisy Chaining) and any cabling on spools must be fully wound out to prevent overheating

  Select Confirmed adherence to the rule.

  • Confirmed adherence to the rule.

• Type of electrical work

  Select Installation of a new circuit/fuse box etc. Replacement of an existing circuit/fuse box etc. Working on the electrics on a device controlling gas/water Voltage levels upto 250v Voltage levels above 250v

  • Installation of a new circuit/fuse box etc.
  • Replacement of an existing circuit/fuse box etc.
  • Working on the electrics on a device controlling gas/water
  • Voltage levels upto 250v
  • Voltage levels above 250v

• Hazards

  Select Electric shock to you and others Site Electrics failure Fire Risk/Ignition of gas/fuel

  • Electric shock to you and others
  • Site Electrics failure
  • Fire Risk/Ignition of gas/fuel

• Precautions

  Select Electrical Isolation Earthing Tag out/Lock Out Non Conductive Tools Barriered Area/Caution Notices Fire Extinguishers/Fire Watchers Gas/fuel line isolation

  • Electrical Isolation
  • Earthing
  • Tag out/Lock Out
  • Non Conductive Tools
  • Barriered Area/Caution Notices
  • Fire Extinguishers/Fire Watchers
  • Gas/fuel line isolation

Other Non- Electrical Hazards

• Are you working at height or task include hot work (Welding, soldering, generating heat/sparks)

  Yes

  No

• You musht complete additional permits (183b Hot Work / 183 Working at Height)

  Complete

• Are you lone Working

  Yes

  No

• What precautions are you taking to ensure your health and safety?

• Are you working outside.

  Yes

  No

• What are the weather conditions

  Select Suitable - OK to proceed Not Suitable - Stop work and wait for improvement.

  • Suitable - OK to proceed
  • Not Suitable - Stop work and wait for improvement.

Waste Disposal

• Are you generating wastes as part of your task.

  Yes

  No

• How are you disposing of the waste?

  Select Harvey waste arrangement (Segregation required) Own arrangement (Advise waste carrier's name)

  • Harvey waste arrangement (Segregation required)
  • Own arrangement (Advise waste carrier's name)

• Name of waste carrier arranged to collect waste.

Emergency Preparedness

• What are your First Aid Arrangements?

  Harvey First Aiders

  Own First Aider

• Have the First Aid team been made aware of your work on site?

  Yes

  No

• First aid team notified

  Complete

Authorisation and Acceptance for task to commence

• On behalf of my company, I authorise the work to be undertaken having personally examined the work site and all the documentation and confirm the precautions taken are adequate and conform to the company EHS Policy

• Issued by:

• Authorised Signature

  Sign

• On behalf of Contract Supervisor/Manager I have personally examined the work location and have read and understood this form. I undertake to ensure that all works are carried out in accordance with this permit, the company EHS Policy

• Issued To:

• Authorised Signature

  Sign

End of Day, worksite safe declaration

• Work progressing to satisfaction, as per the job order. All work materials, wastes and equipment have been removed. Any isolations/lock out tags have been removed and services restored (If work complete). The area is safe to recommence normal working activities.

  Yes

  No

• Work site issues must be addressed before the end of day worksite declaration is signed.

• Authorised Signature from Contractor

  Sign

• Authorised Signature from Harvey

  Sign

• Any final remarks/Comments:

  Yes

  No

Job Completion Declaration

• Task Complete

  Yes

  No

• Return to end of day, worksite safe declaration section.

• Work completed to satisfaction, as per the job order. All work materials, wastes and equipment have been removed. Any isolations/lock out tags have been removed and services restored (If work complete). The area is safe to recommence normal working activities.

• Confirmed by Contractor:

• Authorised Signature

  Sign

• Witnessed by :

• Authorised Signature

  Sign