Title Page
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Company
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Location
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Conducted on
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Validity - Start Time
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Validity - Estimated completion time
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Prepared/Arranged by
General details
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Job details and description.
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Tools/machinery to be used
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Is any other work currently being undertaken that may interact or effect this permit?
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Are measures in place and all effected notified?
Hazards and Precautions to be taken
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Are all risk assessments and method statements in place?
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Is the area clean and free from hazards?
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Will the work involve Construction/Demolition? (Additional permits maybe required)
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Will the task involve working at heights? Including MEWP's, scaffold, ladders and roof access. (Additional permits maybe required)
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Ladder training and MEWP licence's in order?
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Are the weather conditions acceptable?
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Is work required on LV electrical distribution systems?
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Is LOTO required? Can the equipment be isolated and all forms of electricity removed?
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If LOTO is required which services are to isolated? (valve no', circuit ref') And lock number applied.
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Is LOTO training in place and at the correct level for the task?
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Are there pressurised systems and or hazardous fluids/substances to consider and measures in place to prevent injury?
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Have all feed valves been closed, locked and clearly labelled if required?
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Is there potential for an explosive atmosphere?
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Is there a risk from Legionella?
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Is there a risk of coming into contact with Asbestos?
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Is there a risk from Ionising and or non Ionising radiation?
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Is there a risk of heavy lifting? (manual handling) Or using heavy lifting equipment, and are measures in place to manage the risk?
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Have all managers and employees effected by the work been notified and signage put in place?
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Have all workers been assessed as competent to perform the tasks required or closely supervised by someone who is competent?
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Is all tooling required in good order and appropriate for the tasks? PAT tested if required?
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Will excavation be required? (This may require an additional permit)
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Will the task require entering a confined space? (This will require an additional permit)
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Do atmospheric tests need to be carried out?
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Is breathing apparatus available if required?
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Has all motive power been identified and removed or measures in place to prevent injury?
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Are any hot works to be done? *This will require an additional Hot work permit before work commences.
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Is the correct PPE available and in good working condition?
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Is there a risk of product contamination?
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Will the work put anyone in the vicinity of a hazardous area such as a railway track, river, overhead power lines or workplace traffic such as FLT's?
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Are there any other hazards or precautions which need to be covered on this permit to perform the tasks safely? Please give full details of tasks and measures in place.
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 the permit Issuer
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Full name of the acceptor and competent person/person in charge
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Full Name and Signature of Duty manager.
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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 the acceptor and competent person/person in Charge
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Full name and signature of the permit issuer
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Full Name and Signature of Duty manager.
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Date and Time
