Permit to Work Template for Maintenance

• Permit Number

• Contracing Company

• Location
  Address

• Conducted on

  Date

• Prepared by

• Scope of Works

• Permit valid from

  Date

• Permit valid to

  Date

Isolation/Lock Out/Tagout

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

• Electricity

  Yes

  No

  N/A

• Point of Isolation

• Gas

  Yes

  No

  N/A

• Point of Isolation

• Water

  Yes

  No

  N/A

• Point of Isolation

• Air

  Yes

  No

  N/A

• Point of Isolation

• Fire Alarm System

  Yes

  No

  N/A

• Point of Isolation

• Fire Sprinkler System

  Yes

  No

  N/A

• Point of Isolation

Precautions

• 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.)

Completion

• Full Name and Signature of Contractor Site Supervisor

  Sign

• Full Name and Signature of Client Authorizing Person

  Sign