Title Page
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Conducted on
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Prepared by
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Location
1. PERMIT ISSUE
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Permit Number:
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Work on or near HV equipment is unacceptable and MUST NOT proceed. This permit is for Low Voltage (LV) only isolated by a Competent and Authorised Person.
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Building Name:
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Project Number:
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Location of Work:
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Description of work:
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Permit starts:
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Date:
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Time:
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Permit expires:
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Tick if completed
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Risk assessment and method statements/safe systems of work documented and workers aware of / trained in findings
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Those undertaking the work have appropriate qualifications and experience?
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Equipment isolated from all sources of supply?
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Circle as applicable
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Loss of service has been cleared with building users?
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For isolation points not adjacent to work area, warning signs are displayed showing that work is being undertaken on the system?
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For isolation points not adjacent to the work area, locks are applied and keys restricted to those doing the work (using multi locks where more than one worker is involved?
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Stored energy within equipment completely dissipated?
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Equipment has been proved dead?
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Electrical hazard signs displayed next to live equipment which is adjacent to work area?
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Additional earthing installed if necessary?
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Specific safety requirements before commencing work:
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Details of isolation points: include mechanical, electrical and pipework isolations
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Name (Block Capitals):
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Signature:
2. RECEIPT (To be completed by person responsible for the work prior to commencement)
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I understand the scope of works and precautions to be undertaken:
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3. EXTENSION OF PERMIT (If required)
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Time extension:
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Start:
End:
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Authorised person signature:
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Signed for those undertaking the work:
