Title Page
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Site conducted
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Conducted on
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Prepared by
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Location/Area/Floor
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Permit Number
Precautions Required
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Is the electrical panel properly labeled with circuit breakers identified?
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Are all covers and protective guards installed on the Electrical panels
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Have incomplete circuits been disconnected or locked off
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Is there signage on the riser doors and working area
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Please upload a picture showing the condition of the main electrical panel.
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Are the Rams been signed
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What riser keys have been signed out
Permit holders Details
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RNM Authorised Person
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Confirm specific risk assessment and method statement for works being undertaken-RNM AP to review and approve.
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Sub-Contractor
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Permit holder Name
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Permit holders Phone number
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Select time
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Notes/comments
Receipt
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I Declare that i accept Responsibility for carrying out the described works in the area detailed in this Permit to work and that no attempt will be made by me, or by any persons under my control, to approach to carry out work in any other controlled area or associated equipment.
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Sub contractor Signature
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Select time
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Notes and comments
Clearance
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Hereby declare that all persons under my charge have been withdrawn from the controlled area and warned that it is no longer permitted to carry out the work described under this Permit
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Sub contractors Signature
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Has the area been locked off and keys returned
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Notes/Comments
Cancellation
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I hereby declare that this permit cancelled and all associated keys returned.
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RNM AP Signature
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Date
ON THE COMPLETION OF THIS WORK THE HOLDER MUST SURRENDER THIS PERMIT FOR CANCELLATION, AFTER WHICH NO WORK MUST BE CARRIED OUT IN THE AREA SPECIFIED
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PERMT HOLDER: The responsible person in charge of the work to be carried out.
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It is the reasonability of the permit holder to ensure:.
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That they understand the work activity to be carried out and recognise the hazards to be avoided.
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That they have read the content, signified to the Authorised Person that they are fully understanding the instructions and accepted reasonability for carrying out the work by signing this document.
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That no approach will be made, or work carried out in any other controlled area or associated equipment, by the permit holder or anyone under their control.
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That no unauthorised persons are allowed into the restricted area covered by this permit.
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That any doors to restricted areas are locked at all times when the area is left unoccupied. All keys issued under this permit are under the sole control of the permit holder.
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That the restricted area is secured on the completion of the work or at the end of the shift and left in a clean and tidy state with all materials removed.
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That any other permit holders working in the restricted area are notified when you are vacating the area.
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That the permit it always displayed by the permit holder or readily available.
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The permit clearance is signed by the permit holder and returned with any associated keys to the authorised person at the designated site Permit office on the completion of the works or at the end of the shift within the specified times.
