Permit to work on / test* essentially live equipment

• Site conducted

  Select

• Permit Number:

• Associated PTW Number:

• Associated Permits:

• Work specified in the Permit is conditional on all contractors having read, understood and signed the Health & Safety policy.

• Company name:

• Competent person in charge:

• Other personnel engaged in or observing the works:

When:

• From:

  Date

• Until:

  Date

Where:

• Description of works

• Comments / Special conditions:

Safety precautions:

• Safety equipment – The following safety equipment will be provided and used throughout the work / test*

• pairs of insulating rubber gloves - Maximum safe voltage

• pairs of insulating rubber boots - Maximum safe voltage

• insulating rubber mats - Maximum safe voltage

• insulating push bars - Maximum safe voltage

• Other tools and equipment: State type and when to be used

• Adjacent live equipment – State precautions to be taken to ensure that personnel cannot come into contact with adjacent live equipment

• Danger and caution notices – State where caution / danger notices have been posted

• Atmospheric conditions – State tests for flammable substances and precautions to be taken to avoid danger from wet and humid conditions

• No electrical work is to be carried out in potentially flammable atmospheres

Approvals:

• Approved by:

• Date:

  Date

• Signature:

  Sign

Acceptance:

• Acceptance – Competent person: I acknowledge receipt of this Permit and understand the hazards of this work / test* and the safety precautions described above. I have ensured that these have been fully explained to the personnel carrying out the work / test* and consider them competent to do it safely. I will closely supervise the work / test* to ensure that they are carried out in accordance with the terms of this permit and will work / test* only under the supervision of the Observer. I will return this Permit to the Authorised Person when the Work / Test* is complete. In the event of an emergency I will cease the work safely and comply with the Site emergency procedures. Work will only recommence when a new risk assessment has been done and a new permit issued.

• Accepted By:

• Date:

• Signature:

• Acceptance – Observer: I acknowledge receipt of this Permit and will monitor the safe progress of the work / test*. I have been instructed in what to do in the case of an emergency and will return this Permit to the Authorised Person when the Work / Test* is complete.

Clearance:

• Clearance: I declare that the Work / Test* detailed above has been completed / stopped*. The apparatus is safe and personnel and equipment have been withdrawn.

• Returned by:

• Date:

• Signature

Closure:

• Closure: I hereby declare this Permit closed. The original copies of the Permit have been returned to me by the Competent Person and Observer. I have inspected the Work / Test* location and I am satisfied that the apparatus and location have been left in a safe condition.

• Closed By:

• Date:

  Date

• Signature:

  Sign