PERMIT TO WORK OR TEST (ELECTRICAL)

• Ref Number

• Duration of Permit

• I certify that the following apparatus has been made dead, electrically isolated, earthed if necessary and that all other relevant measures have been taken to ensure that the work and/or tests specified below can be performed in a safe manner.

• Part A
  Address

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• Plant/equipment/system *

• Location:

• Work/tests * to be completed:

• Location of:

• Other precautions:

• Diagram attached (if required)

  Yes

  No

  N/A

• Please indicate if any other permits are in use (if so, describe and provide ref no):

• Details of testing to be undertaken to prove the apparatus is safe to reenergise (including type of test and expected results to prove safe)

• Test Type

• Expected Results

• Name of authorised person issuing permit:

• Signature

  Sign

• Select date

  Date

• Receipt: I hereby acknowledge receipt of this permit having inspected the above safety precautions. I am satisfied that the precautions taken are adequate and I accept responsibility for undertaking the work specified above in a safe manner. I declare that neither myself nor those persons within my control will attempt any other task than that specified above.
  
  

• Name of competent person(s) undertaking work:

• Name of Company

• Signature

  Sign

• Date and Time

  Date

Part B

• Ref Number

• Duration of permit:

• I certify that the work certified above has been completed/stopped*, that all personnel, tools and equipment within my control has been removed from the work area and that the above safety measures may/may not* be removed.

• Details of testing undertaken to prove the apparatus is safe to reenergise (including type of test and results to prove safe)

• Test Type

• Actual Results of Tests

• Signature of competent person undertaking work:

  Sign

• Company:

• Date and Time

  Date

Cancellation

• I certify that the above system measures have been removed and that the plant/equipment/system* is safe to operate and is hereby returned to normal service. All copies of this permit work are hereby cancelled, and a master copy will be kept for record purposes.

• Details of testing WITNESSED to prove the apparatus is safe to reenergise (including type of test and results to prove safe).

• Test Type

• Actual Results of Tests

• Signature of Authorised Person:

  Sign

• Date and Time

  Date