Electrical work permit

• Client / Site

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Electrical Work Permit

• Permit No:

• Work Location:
  Address

• Description of work being conducted:

• Permit Valid FROM:

• Date & Time:

  Date

• Permit Valid TO:

• Date & Time:

  Date

• All fields must be completed, indicate with either YES, No or N/A (Not applicable).
  Permit numbers must be listed also.

Does this Permit combine with any other Permit or Permits?

• Isolation Permit

  Yes

  No

  N/A

• Permit No:

• Confined Space Permit:

  Yes

  No

  N/A

• Permit No:

• Hot Works Permit:

  Yes

  No

  N/A

• Permit No:

• Excavation Permit

  Yes

  No

  N/A

• Permit No:

• Working at height

  Yes

  No

  N/A

• List Permit & No:

Answer all questions below with Y, N or N/A.

• All personal working on this Task are trained & Competent?

  Yes

  No

  N/A

• A Current Risk Assessment has been completed for the work this permit is applicable to?

  Yes

  No

  N/A

• The apparatus is effectively connected to earth at the following points

  Yes

  No

  N/A

• The points of isolation are as follows

• Arrangements for the display or retention of the keys to locking-off devices are as follows

• Caution notices have been posted at the following points

• Safety locks have been fitted at the following points

• Description of the work to be carried out

Authority for electrical work

• Responsible Person. (Applicant/Contractor)
  I Accept the responsibility of this Permit as the person directly in charge of the work.

• Name & Sign:

  Sign

• Date & Time:

  Date

• Authorising Person. (Site Manager)
  I have advised the person nominated above of the conditions of this permit and authorise Working at Heights to be carried out subjected to the conditions of the risk assessment.

• Name & Sign:

  Sign

• Date & Time:

  Date

Electrical works Personal I have been trained, I have read and agree to the conditions of this Permit

• Name and Sign ON:

Person

• Name & Sign

  Sign

• Date & Time

  Date
Electrical Personal Name and Sign OFF:

• Name & Sign

  Sign

• Date & Time

  Date

Permit Closure (To be completed by Responsible Person)

• All electric has been returned, inspected and accounted for?

  Yes

  No

• All work associated with this Permit has been completed. The work and adjacent areas have been inspected and have been left in a safe condition.

  Yes

  No

• List any Controls left in place:

• Name & Sign:

  Sign

• Date & Time:

  Date