Title Page
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Site conducted
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Job details
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Special tools to be used
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Location
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Is any other work currently being undertaken that may interact or affect this permit to work?
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What other work is being undertaken that may interact or affect this permit to work?
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This permit is only valid when all sections are completed. If you are in doubt or don't understand, then please ask. Please ensure that you sign this permit-to-work.
Hazards and Precautions to be Taken
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Do not proceed with your work until your permit has been authorised by the relevant member of staff.
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Primary hazards - fumes, electrics, gases, liquids, sludge, fire, smoldering.
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Please answer the following questions truthfully.
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Are you qualified / trained to undertake this work?
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Has a sprinkler system / fixed fire installation been left in service?
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Are there extinguishers to hand?
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Are there means of sounding the fire alarm to hand?
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Is the area cleared of combustible material and / or protected?
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Have any flammable liquid containers been removed and / or protected?
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Are the walls / floors (including gulley's and combustible construction) suitably protected by fire blankets?
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Is the area to be wetted out or fir blanket to be used?
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Is there a competent person, trained in the use of a fire extinguisher in attendance throughout the work and for 60 mins after?
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Is Personal Protective Equipment required?
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Please list the Personal Protective Equipment to be used.
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Are there any other safety precautions required not listed above?
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Please list the other safety precautions required.
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Is there any other safety equipment required to carryout the job?
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Please list the other safety equipment required.
Authorisation and Acceptance
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By signing this permit-to-work you are confirming that you have verified all the previous information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined previously and the permit information has been explained to all workers involved.
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By signing this permit-to-work you are accepting responsibility for this work.
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Name of person in charge
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Name of company
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Signature
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Date and time of signature
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Name of authorising person
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Signature of authorising person
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Date and time of authorising signature
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Expiration date and time of this permit-to-work
Post Area Works Inspection
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By signing this you are confirming to have carried out a check / inspection of the area for combustion 1 hour after completion of the works.
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Name of person in charge
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Signature of person in charge
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Date and time of check / inspection
Hand Back and Cancellation
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I confirm that the work as stated in this permit-to-work has been completed / partially completed*, checked by myself and the area left safe and in a tidy condition. (*delete as appropriate)
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Name of person in charge
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Signature of person in charge
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I have inspected the complete / partially complete* work and herby cancel this permit. (*delete as appropriate)
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Name if authorising person
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Signature of authorising person
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Date and time of handback
