Permit To Work Certificate

• Contractor Company

• Area of Work

• Valid From (Date + Time)

  Date

• Valid Until (Date + Time)

  Date

• Jigsaw Responsible Person

• Contractor Responsible Person

• Details of Work

• Are Further Permits Required

  Yes

  No

• If Yes Choose From Following

  Select N/A Hot Work Work at Height Confined Space Fragile Roof High Voltage Excavation

  • N/A
  • Hot Work
  • Work at Height
  • Confined Space
  • Fragile Roof
  • High Voltage
  • Excavation

Further Information

• Are there RAMS for this Project ? If not and you are in any doubt whether they are needed contact H&S for advice

  Yes

  No

  N/A

• Discuss with the contractor how the project will be done and how you will mitigate any hazards to ALARP. Has this been Done

  Yes

  No

• Is the scissor lift to be used (Full WAH Permit not needed)

  Yes

  No

• Do we have a copy of the contractors IPAF 3A certificate

  Yes

  No

• Has the Contractor Induction Agreement been Received / Completed

  Yes

  No

• Are You willing to Sit the Induction now

  Yes

  No

• Please Leave site, do not start work !!

• Equipment to be isolated

  Yes

  No

• Electrical Lock off to be applied

  Yes

  No

• Compressed Air ,Liquid Pipeline, Gas, Fuel to be drained and cleaned

  Yes

  No

• Is nearby equipment safe for work to proceed

  Yes

  No

• Have other departments been informed where necessary

  Yes

  No

• Are barricades, hoarding or cordons required

  Yes

  No

• Are warning notices needed ? if yes they must be posted

  Yes

  No

• Is there adequate access, and Lighting

  Yes

  No

• Are other permits live in the area

  Yes

  No

• Do contractors have required PPE, including specialist PPE, Minimum safety shoes and hi-viz vest.

  Yes

  No

• Will the Jigsaw Representative be on site for periods when the contractor is on site.

  Yes

  No

• Name of supervising Jigsaw Employee

• Are all laws and regulations complied with

  Yes

  No

• Do you Require any Further advice from H&S Department

  Yes

  No

Jigsaw Foods Responsible Person sign as all information correct and sign over to contractor

• Jigsaw Foods Responsible Person Name / Signature

  Sign

• Contractor / Engineer Name / Signature

  Sign

Sign Off - Work complete and area left in a safe and tidy condition - Checked by Jigsaw Foods responsible person

• Jigsaw Foods Responsible Person Name / Signature

  Sign