Title Page

  • Permit No.

  • Contracting Company

  • Location
  • Conducted on

  • Prepared by

General details

  • Job details

  • Tools to be used

  • Is any other work currently being undertaken that may interact or affect this permit?

  • Specify other work

Hazards and Precautions to be taken

  • Are the weather conditions acceptable?

  • Is the area clean and free from hazards?

  • Is the plant or system isolated and free from every source of danger?

  • Have all feed valves been closed and locked?

  • Is adequate signage displayed?

  • Have all workers been assessed as competent or closely supervised by someone who is competent?

  • Are tools repaired or replaced when needed.?

  • Have atmospheric tests been satisfactorily carried out?

  • Has the electrical supply been switched off?

  • REFERENCE: Electrical supply switched off
    [This is an example of how you can use iAuditor to include best practice reference images in your templates to assist with inspections]

  • Is breathing apparatus available?

  • Are PPE available and in good working condition?

Authorization and Acceptance

  • I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the permit information has been explained to all workers involved. I accept responsibility for this work.

  • Full Name and Signature of Person in Charge

  • Full Name and Signature of Authorizing Person

  • Date and Time

Hand Back and Cancellation

  • I confirm that the work has been completed/partially completed, checked by myself and the area left in a safe and tidy condition.

  • Full Name and Signature of Person in Charge

  • Full Name and Signature of Authorizing Person

  • Date and Time

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.