Title Page
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Permit No.
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Contracting Company
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Location
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Conducted on
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Prepared by
General details
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Job details
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Date and time works are to commence
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Date and time works are to be completed
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Risk Assessment has been provided and approved
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Hazard identified
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Tools to be used
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Is any other work currently being undertaken that may interact or affect this permit?
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Specify other work
Hazards and Precautions to be taken
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Are the weather conditions acceptable?
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Is the area clean and free from hazards?
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Is the plant or system isolated and free from every source of danger?
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Have all feed valves been closed and locked?
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Is adequate signage displayed?
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Have all workers been assessed as competent or closely supervised by someone who is competent?
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Are tools repaired or replaced when needed.?
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Have atmospheric tests been satisfactorily carried out?
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Has the electrical supply been switched off?
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Is breathing apparatus available?
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Are PPE available and in good working condition?
Authorization and Acceptance
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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.
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Full Name and Signature of Person in Charge
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Full Name and Signature of Authorizing Person
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Date and Time
Hand Back and Cancellation
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I confirm that the work has been completed/partially completed, checked by myself and the area left in a safe and tidy condition.
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Full Name and Signature of Person in Charge
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Full Name and Signature of Authorizing Person
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Date and Time
