Title Page
-
Permit Number
-
Site conducted
-
Conducted on
-
Prepared by
-
Sub-contractor requesting permit
-
Location of works Block, Level, Apartment/ switchroom
-
PART 1 - PERMIT HOLDER DETAILS
-
Confirm risk assessment and method statement is specific for works
-
Permit holder name
-
Other persons in permit area (Names)
-
Telephone number
-
Email Address
-
PART 2 - AUTHORISATION FOR WORKS TO COMMENCE
-
The above-named person has been competency checked and is hereby given permission to carry out the work described in the controlled area and on the equipment detailed below. I hereby declare that the equipment in the area specified is dead and isolated from all live conductors.
WORK MUST NOT BE CARRIED OUT IN ANY OTHER AREA OR ON ANY OTHER EQUIPMENT.
TREAT ALL OTHER EQUIPMENT AS DANGEROUS -
Location/Area and Description of Work: (Detail any charts or diagrams relevant to work area)
-
Any other hazards involved i.e. permits issued to other parties:
-
Points at which system is isolated:
- Main isolator LV Panel
- Main isolator Apartment
-
Points at which the system is Earthed:
-
Other:
-
Points at which Safety Locks have been fitted:
-
Points at which Caution Notices have been posted:
-
Keys / Padlocks Issued:
-
Person in charge of work signature (Sub contractor)
-
Cilantro AP Signature:
-
Time
-
PART 3 - CLEARANCE/ SUSPENSION
-
I hereby declare that the work for which this Permit To Work was issued is now *Completed/*Suspended and all people under my charge have been withdrawn and warned that it is no longer safe to work on the apparatus detailed on this Permit To Work. All work equipment, tools test instruments etc have been removed and all associated keys returned.
-
Type
-
If suspended state reason for suspension
-
Person in charge of work signature (Sub contractor)
-
Time
-
PART 4 - CANCELLATION/ SUSPENSION
-
I hereby declare this Permit To Work *Cancelled/*Suspended and all associated keys returned.
-
-
Cilantro AP Signature:
-
Time
-
Sub-Contractor Signature
-
PERMIT HOLDER: The Responsible Person in charge of the work to be carried out.
This permit must not be used in situations where a Sanction For Test or Limitation Of Access is required.
It is the responsibility of the permit holder to ensure: -
That they understand the work activity to be carried out and recognise the hazards to be avoided.
That they have read the content, signified to the Authorised Person that they fully understand the instructions and accepted responsibility for carrying out the work by signing Part 2.
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.
That no unauthorised persons are allowed into the restricted area covered by this permit.
That any doors to restricted areas are locked at all times when the area is left unoccupied. All keys and padlocks issued under this permit are under the sole control of the permit holder.
That the restricted area is secured on completion of the work or at the end of the shift and left in a clean and tidy state with all materials removed.
That any other permit holders working in the restricted area are notified when you are vacating the area and that the permit is always to be displayed by the permit holder on the armband issued to them and is not to be taken from the site.
The permit Part 3 Clearance/Suspension is signed by the permit holder and returned with any associated keys to the Authorised Person at the designated site permit office at the end of the shift within the specified times. The permit shall be “suspended” if works are incomplete and must be re applied for by the permit holder to continue work.
Part 4 Cancellation/Suspension will then be completed by the Authorised Person and any keys and padlocks are signed back in.
