PCBU Company Details

Company Name of Permit requestor

Contact details of the permit requestor supervisor

Permit Details
Time and Date permit becomes active
Time and Date permit will become deactive
Permit issued to

Description of the Hot Work to be undertaken

Sketch of location if required

Fire fighting equipment to be on hand as part of this activity

Fire extinguisher

Sand bucket

Water supply

Fire blanket

Other equipment to be at the ready for this activity

Control Measures

What will be the method for raising the alarm, should a fire break out

Details of raising the alarm

Drains and Pits are covered or isolated

Is the area adequately ventilated

Spark flash screens in place

Area isolated or barricaded off

Fire load reduced, protected or isolated

Fire equipment has been checked, laid out and is fit for purpose.

Will weather conditions potentially effect this task, if so what extra precautions will be enlisted

Other details

Fire watch if required

Details of how the fire watch will be deployed, location, equipment, time post event still required, communication details between hot work and the fire watch person.

Sketch the fire watch location if required.
Weather conditions if relevant

If weather conditions such as wind or excessive heat will impact on the activity, what precautions will be taken

Completion of Hot Work Inspection
Time and Date post activity inspection undertaken

Details of the post activity inspecton

Name of person undertaking the post activity inspection

Signature of inspecting person
Permit Cancelation

Notes or relevant details if required

Time and Date permit terminated
Matrix staff member terminating this permit
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.