Title Page
-
Site conducted
-
Conducted on
-
Prepared by
-
Permit Number (Job number)
-
Issuer of Permit
-
Receiver of Permit
Part 1 - Isolation of LV Electrical Supplies
-
Contract
-
Job/Project/Premises
-
City FM Competent Person
-
Work requested by
-
Date & Time
Part 2 - Scope of Work and Isolation Details
-
Description of Work
-
Equipment to be isolated
-
Circuit isolated at and ref no.
-
Means of isolation
-
Lock of by
-
Warning notices posted at
-
Approx. duration of isolation
Part 3 - Issue
-
I confirm that the isolation of the equipment as detailed in Part 2 has been carried out
-
Signature of City FM competent person
-
Name
-
Date & Time
Part 4 - Dead Works, Inspection and Testing
-
I confirm that the works have been undertaken dead and the appropriate dead inspection and testing of the equipment has been carried out.
-
Signature of City FM competent person
-
Name
-
Date & Time
Part 5 - Cancellation
-
All works have been completed, tested and certified and where applicable, the Client has been informed of completion. The circuit described in Part 2 has been re-energised.
-
Signature of City FM competent person
-
Name
-
Date & Time
-
Following cancellation, comply with the safe systems of work for Live Testing procedures.
