• What works will be undertaken?

  • Special Tools / Equipment to be Used

  • Job Location / Plant Identification Number

  • Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

This Permit is only Valid when all sections are complete. If you are in doubt or don't understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE RELEVANT MEMBER OF STAFF.


PRIMARY HAZARDS - Fire, Fumes, Electrical, Explosion, Gases & Smouldering / Smoke

Please answer the questions truthfully

  • Are you Qualified / Trained to undertake this work?

  • Has the Fire Sprinkler System been left in service?

  • Are 2x Fire Extinguishers available at the work location? Are they the correct type for the equipment in the area?

  • Is a Fire Blanket Available for Clothing Fires?

  • Is there a means of sounding the site fire alarm in the vicinity of the works?

  • Have the Fire Alarm Sensors near the works being isolated / impaired to prevent accidental activation of the fire alarm?

  • Is the work area clear of combustible materials?

  • Are walls / floors (Including Gulleys / Combustible Voids) suitably protected by Fire Blankets?

  • Are the vessels / lines isolated (LOTO)/ Capped with Blinds and purged of flammable liquids?

  • Is the work area wetted out if required?

  • Is there a Fire Watch Trained person on standby with a Fire Extinguisher at all times when the works are in progress, and for 60 minutes after work is completed?

  • Is continual gas monitoring required?

  • Is intrinsically safe equipment required i.e. Non-Sparking CuBe Tools or ATEX Rated Electrical Equipment?

  • Are personnel wearing flame retardant overalls / boots and gloves?

  • Are personnel wearing eye protection / head protection if required?

  • Is atmosphere test required? If yes, complete section below.


  • Insert Time of Atmosphere Test 1

  • Oxygen %

  • Oxygen %

  • Carbon Monoxide %

  • Carbon Monoxide %

  • Combustible Hydrocarbons %

  • Combustible Hydrocarbons %


  • Insert Time of Atmosphere Test 2

  • Oxygen %

  • Oxygen %

  • Carbon Monoxide %

  • Carbon Monoxide %

  • Combustible Hydrocarbons %

  • Combustible Hydrocarbons %


  • Do any other precautions need to be put in place to allow the works to proceed safely?

  • Is any other safety equipment required for the works to proceed safely?

AUTHORISATION & 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 works as defined above and the permit has been explained to all workers involved. I accept responsibility for this work.

  • Person in Charge of Works

  • Company

  • Signature

  • Authorising Person


  • Permit Expires on


  • Name of Person Undertaking Fire Watch

  • Fire Watch Start Time

  • Fire Watch Finish Time

Minimum Fire Watch period is 60 minutes after works are completed.


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

  • Person in Charge (Print Name)

  • Person in Charge (Signature)

I have inspected the completed work, confirmed fire watch is completed and returned any isolated fire protective equipment (Alarms / Sprinklers) to its normal status. I hereby cancel this permit.

  • Authorised Person (Print Name)

  • Authorised Person (Signature)


  • Permit Cancelled

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