Title Page
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Permit Number
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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/ Equipment/ Room
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Sub-contractor
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PART 1 - PERMIT HOLDERS DETAILS
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Confirm specific risk assessment and method statement for works being undertaken - Cilantro AP to review and approve.
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Permit Holder Name
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Phone Number
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Email Address
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PART 2 - AUTHORISATION FOR WORKS TO COMMENCE
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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.
WORK MUST NOT BE CARRIED OUT IN ANY OTHER AREA THAN THAT IS DETAILLED WITHIN THIS PERMIT -
Additional Persons
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DO NOT START ANY WORKS ON ELECTRICAL INSTALLATIONS UNTIL THE IOSLATOR IS IN OFF POSITION AND LOCKED OFF WITH TAG AND PROVED DEAD BY CILANTRO AP
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Hazards present
- Work at Height - Ensure all equipment is ft for purpose and inspected by a PASMA trained person
- Manual Handling - Use mechanical means. Break down load to manageable weights/ sizes
- Mechanical hazards - Observe all warning signage. Do not touch any mechanical equipment. Assume all mechanical equipment is LIVE
- Slips, Trips and Falls - Ensure to clean on a "as you go basis". Keeps tools and equipment out of walkways
- Working around other trades -Barriers and warning signage. Make other trades aware of your work
- Poor lighting -Utilise task lighting where lux levels are poor
- Electrical Hazards - Treat all electrical services as LIVE 230/400V. Contract Cilantro electrical AP for further information or and enquiries.
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Additional hazards please state
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Description of works
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Keys Issued:
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Cilantro AP Signature
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Select date
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Notes/ comments
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PART 2 - RECEIPT
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I declare that I accept responsibility for carrying out the described works in the area detailed in this Limitation of Access Permit and that no attempt will be made by me, or by any persons under my control, to approach or carry out work in any other controlled area or associated equipment.
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Sub-Contractor Signature
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Select date
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Notes/ comments
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PART 3 - 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 Limitation of Access.
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Sub-Contractor Signature
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Photo to confirm area is locked/ left safe
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Notes/ comments
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PART 4 - CANCELLATION
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I hereby declare this Limitation of access permit cancelled and all associated keys returned.
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Cilantro AP Signature
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Select date
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Notes/ comments
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ON COMPLETION OF THIS WORK THE HOLDER MUST SURRENDER THIS LIMITATON OF ACCESS FOR CANCELLATION, AFTER WHICH NO WORK MUST BE CARRIED OUT IN THE AREA SPECIFIED.
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PERMIT HOLDER: The Responsible Person in charge of the work to be carried out.
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This permit must not be used in situations where a Permit To Work or Sanction For Test is required.
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It is the responsibility 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 fully understand the instructions and accepted responsibility for carrying out the work by signing Part 2.
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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 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 is always to be displayed by the permit holder on the armband issued to them and is not to be taken from the site.
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The permit Part 3 Clearance is signed by the permit holder and returned with any associated keys to the Authorised Person at the designated site permit office on completion of the works / at the end of the shift within the specified times. Part 4 Cancellation will then be completed by the Authorised Person and any keys signed back in.
