Title Page

  • Permit Number

  • Contracing Company

  • Location
  • Conducted on

  • Prepared by

  • Scope of Works

  • Permit valid from

  • Permit valid to

Isolation/Lock Out/Tagout

  • Are the following equipment/materials isolated or locked out before any maintenance or installation work:

  • Electricity

  • Point of Isolation

  • Gas

  • Point of Isolation

  • Water

  • Point of Isolation

  • Air

  • Point of Isolation

  • Fire Alarm System

  • Point of Isolation

  • Fire Sprinkler System

  • Point of Isolation


  • Click + to list precautions

  • Precaution
  • Enter details here

Tools and Equipment

  • Click + to list tools and equipment to be used

  • Tool
  • Enter details here (e.g. Scaffold, PPE, Welding sets, 110V Tools etc.)


  • Full Name and Signature of Contractor Site Supervisor

  • Full Name and Signature of Client Authorizing Person

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