Title Page
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This permit is valid only for the time, work, tools, equipment, and personnel listed.
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Permit Number
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Permit Description
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Permit Prepared by
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Date and Time Prepared
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Contractor Name
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Contractor Workers (list all names separated by comma)
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FPC Work Supervisor
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Area Certified Person
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Safety Certified Person
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Permit expiration date and time
Work Description and Location
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Area
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Work Description
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Tools Required
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Hand tools
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Impact tools
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Power drill
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Power saw
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Grinder
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Other Equipment
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List other equipment
General Permit
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Appropriate MSDS available
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Hazardous chemicals transfer stopped
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Equipment cleared of chemicals
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Lockout/Tagout done.
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Overhead work, i.e., crane, cherry picker, etc.
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Affected personnel notified
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Work from scaffolding/manlift/ladder
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Is inspection up-to-date?
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Is Special PPE Required
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Chemical goggles
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Splash shield
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Impact shield
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Welding hood/UV lenses
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Hearing protectors
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Dust masks
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Full face respirator
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Cartridge type
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1/2 face respirator
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Cartridge type
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Supplied air respirator
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Bottle O2 / Breather box check
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Chemical gloves
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Leather gloves
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Slicker required for first break only
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Paper (Tyvek) coveralls
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Body harness / Tie-off
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Rubber boots
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Metatarsal boots
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Personal monitor
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List type of monitor
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Other
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List other
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Barricade Tape/Safety cones in place
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Hot Surfaces Identified and Protected
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Contaminated areas identified & protected
Equipment/Pipe Opening
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Equipment/Pipe Opening
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Equipment/Pipe purged
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Equipment/Pipe isolated
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Proven clear of chemicals
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Watch available for "First Break"
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Name of "First Break" watch
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Other
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List other
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Atmosphere Test
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LEL%
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O2%
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CO%
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Hazardous (Specify)
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Area Certified Person
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GFI Tested
Hot Work
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Single Signature Permit (Low Energy)
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Electric tools not cutting/Drilling process equipment
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Impact/Friction tools
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Energized circuits
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Test equipment/camera
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General purpose area
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Motorized equipment
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Equipment attendant
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Fire blanket
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Fire extinguisher
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Atmosphere Test
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LEL%
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O2%
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CO%
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Hazardous (Specify)
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Area Certified Person Name
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Signature
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Dual Signature Permit (High Energy)
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Open Flame
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Cuts/Drills into process equipment
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Equipment Isolated
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Purge applied (Below 5.5% O2)
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Spark protection provided
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Fire Watch Present
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Name of Fire Watch
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Water Hose and/or Fire Extinguisher Available
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Other
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List Other
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Atmosphere Test
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LEL%
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O2%
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CO%
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Area Certified Name
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Signature
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Safety Certified Name
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Signature
Confined Space/Excavation Entry (Dual Signature Permit)
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Confined Space/Excavation Entry
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Tank/Vessel entry
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Equipment isolated
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Rescue kit available
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Bottle watch
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Name of bottle watch
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Air horn available
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Hole watch
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Name of hole watch
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Radio available
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Rescue plan
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Explain evacuation plan.
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Excavation shored/sloped/trench box
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Space ventilated
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Attendant present
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Atmosphere Test
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LEL%
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O2%
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CO%
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Hazardous (Specify)
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Area Certified Person Name
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Signature
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Safety Certified Person Name
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Signature
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Job Hazard Concerns
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Explain
Worker or Crew Representative
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Representative Name
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Signature
Job Completion / Permit Sign-Off
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Job completed, area cleaned and inspected
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Worker, Contractor, or Crew Representative Name
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Signature
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Area Certified Person Name
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Signature
