Information
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
Electrical Work Permit
-
Permit No:
-
Work Location:
-
Description of work being conducted:
-
Permit Valid FROM:
-
Date & Time:
-
Permit Valid TO:
-
Date & Time:
-
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?
-
Confined Space Permit:
-
Permit No:
-
Hot Works Permit:
-
Permit No:
Answer all questions below with Y, N or N/A.
-
All personal working on this Task are trained & Competent?
-
A Current Risk Assessment has been completed for the work this permit is applicable to?
-
The apparatus is effectively connected to earth at the following points
-
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:
-
Date & Time:
-
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:
-
Date & Time:
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
-
Date & Time
Electrical Personal Name and Sign OFF:
-
Name & Sign
-
Date & Time
Permit Closure (To be completed by Responsible Person)
-
All electric has been returned, inspected and accounted for?
-
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.
-
List any Controls left in place:
-
Name & Sign:
-
Date & Time:
