Part 1 - Work Request

Date/Time from:
Date/Time until:

Description/Type of works:

Area of the building affected

Name of contractor/employee:

Name of contractor/employee:

Company name:

Position:

Part 2 - Safety Review

H&S Policy attached

Environmental Policy attached

Risk Assessment attached

Method Statement attached

COSHH Information attached

Review H&S file (Asbestos etc)

Part 3 - Precautions

General

Inform whoever maybe affected by the work

Communication

Additional access

Ventilation

Lighting levels

Warning signage

Secure the area from the public

Site tour & safety review

PPE

Goggles

Face Shield

Ear Defenders

Gloves

Protective Suit

Face mask

Hard Hat

Safety Harness

Safety Footwear

Other

Special precautions
Are there any additional special works being carried out?
Work at Height

Safe means of access/exit/rescue

Ladders inspected

Weather conditions considered (external work only)

Netting & kicker boards fitted

Scaffolding erected by certificated person

Personnel trained in use of safety harness

Mobile platforms operated by a correct IPAF certificated person

Alloy towers erected by a PASMA certificated person

Confined Spaces

Safe means of access/exit/rescue

Ladders inspected

Weather considered (external)

Gas monitoring equipment within date (if required)

Personnel trained in use of safety harness

Breathing apparatus required

Hot Works

Safety watch (15 minutes & 1 hour sign off after works completed)

Sign to confirm safety watch is complete

Fire fighting equipment

Shields to stop sparks and protect the public and staff

Drains covered

Part 4 - Isolation (for electrical works only)

Are electrical works being carried out?

Equipment to be isolated:

How has the equipment been isolated:

Isolation carried out by:

Isolation carried out at:

Circuit proved dead at:

Date/Time circuit proved dead:

Part 5 - Authorisation PfPLM

Subject to the stated conditions the work specified above is authorised to commence

Name:

Position:

Authorised at:
Authorisation by PfPLM

Part 6 - Acceptance Contractor

I accept the the conditions of the permit as stated above/previous and will ensure that all personnel comply with the conditions of the permit

Name:

Position:

Authorised at:
Signature of head contractor

Part 7 -Transfer

To be completed by the person surrendering the permit and the person receiving the permit

Transferring persons:

Transferred from (name):

Date/time transferred from:

Transferred to (name):

Date/time transferred to:

Part 8 - Work Completed

The work has been completed to the required quality standards as set out in line with point 7.
All additional earths have been removed and the isolation removed (electrical only).

Name:

Position:

Date/Time
Signature by contractor

Part 9 - Permit Cancellation/Completion

The permit is now cancelled

Name:

Position:

Date/Time
Signature by PfPLM employee
General Manager sign off

Name:

Position:

Date/Time
Signature by General Manager
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.