Title Page

  • Site conducted

  • Permit number

  • Location
  • Site emergency phone numbers

  • Conducted on

  • Prepared by

  • Contractor

  • Contractor Supervisor

  • Name(s) of the operative(s) - only named operatives will be allowed access

  • Contact(s) of the operatives(s) - mobile phone number(s)

  • Access Fobs and access keys requested

  • Location of work


  • Description of work to be carried out

  • Are there other practicable alternatives to working at height? (if yes prohibit work at height)

  • Refer to Facade Access & Maintenance doc attached

  • Is the Contractor approved through Permissions Process and documentation approved?

  • It is a Living by Lendlease requirement that the FM Team, checks the performance of the contractor at least once during the permitted works – have you time to do this monitoring? (if not the work should not proceed)

  • Were the RAMS received and approved?

  • Refer to RAMS doc attached

Specific Safety requirements before commencing work

  • Are the correct numbers of operatives as per the Method Statement on-site? (If the team is short then the activity should not be allowed to begin)

  • Operatives are aware of the Fire Emergency Plan.

  • Operatives are aware of the rescue procedures that they have in place for this building

  • Reporting procedures in place, contact numbers and radios have been issued

  • Safety Zone has been created

  • Appropriate measures have been taken to protect others from falling materials or objects

  • Wind speed readings to be taken and recorded: wind speed must not exceed* mph. m/s (insert as per risk assessment) in the immediate vicinity of the work


  • Harnesses must be worn at all times whilst working and in the cradle.

  • Do operatives have the PPE listed on the Method Statement and Risk Assessment?

  • Other protective equipment being used such as warm clothing, waterproofs, hearing or eye protection, gloves etc;

Safety Confirmation

  • Confirmation that there are no reasonably practicable alternatives to this work to make it safer?

  • Permit Starts

  • Permit Ends

Acknowledgement of Permit to Work Conditions

  • The holder of the permit is the employee of a company that has been appointed in accordance with Living by Lendlease procedures or is an authorised employee of Living by Lendlease

  • The holder of the permit complies with the restrictions and conditions detailed in the permit and attached to it (where applicable)

  • The holder of the permit complies fully with all the requirements of the documents HSE Requirements for Contractors, Environmental Site Rules for Contractors, Health and Safety Policy, Environmental Policy

  • The holder of the permit ensures that he/she/they (or his/hers/their employees as appropriate) are provided with means of communication in the event of an emergency whilst on this site

  • Any change in the scope of work or failure to follow conditions identified in this Permit will automatically invalidate the permit. All proposed changes must be notified to the person who issued the permit (Authorised Person)

  • The Permit cannot be transferred between contractors or shifts. In such cases, a new Permit will be issued.

  • In an emergency, the permit holder should follow site emergency procedures. In such cases, the permit will automatically become void and a new permit will need to be issued before work can start again.

  • Where work is suspended for any reason, the permit will automatically become void and a new permit will be needed before work can start again.

  • I understand the scope of works, Living by Lendlease Conditions of issue and precautions agreed to be undertaken.

  • Contractor

  • Permit holder signature

Extension of Permit to Work

  • Time Extension

  • Start

  • End

  • Reason for Extension

  • Authorised person signature

  • Contractor Supervisor signature


  • Safety Zone has been removed and any equipment returned to stores

  • Confirmation of any isolation of services are cancelled

  • All waste materials, equipment and materials have been removed from the roof area in a safe manner

  • All equipment returned (Radios, Keys) and any faults reported

  • Contractor Supervisor signature

  • Date & Time

The Permit is now cancelled

  • Authorised person signature

  • Date & Time


  • Were any poor health and safety practices identified?

  • Did you have to prohibit work or give any official warnings?

  • Was work being carried out in accordance with the Permit to Work?

  • Was work being carried out in accordance with risk assessments and method statements?

  • Did contractors have copies of the Permit to Work?

  • Was the contractor complying with the site rules?

  • Was the work area suitably protected i.e. fenced / barriered and adequate safety signage provided?

  • Was housekeeping acceptable?

  • Completed by:

  • Position:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.