Work Permit - Electrical

• Site conducted

  Select
• Location
  Address

Part A - Complete Prior to the Commencement of Work

• Issued to Name:

• Company Name:

• Valid From (Time & Date):

  Date

• Valid To ( Time & Date):

  Date

• Plant/Area to be Worked on:

• Location of Works:

• Details of Work / Tests to be Completed:

• Special Precautions Required:

  Select Isolation Lockout Special Notices Earthing Other Noted Precautions

  • Isolation
  • Lockout
  • Special Notices
  • Earthing
  • Other Noted Precautions

• Provide details below:

• Diagram Attached

  No

  Yes

• Please indicate if any other permits are in use

  Select Hot Works Working at Height General Confined Spaces

  • Hot Works
  • Working at Height
  • General
  • Confined Spaces

Authorisation

• Name of authorised person issuing permit:

  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 and Signature of competent person undertaking work:

  Sign

• Select date

  Date

PART B - POST COMPLETION OF WORK

Clearance

• I certify that the work detailed in Part A has been completed / stopped, that all personnel, tools and equipment within my control have been removed from the work area, and any safety precautions introduced have also been be removed.

  Completed

  Stopped

  Cancelled

• Name & Signature of competent person undertaking work

  Sign

• Select date

  Date

Cancellation of Permit

• Select date

  Date

• Has the permit been cancelled

  Yes

  No

  N/A

• I certify that the precautionary measures detailed in Part A 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 to work are hereby cancelled and a master copy will be kept for record purposes.

• Ace Express Authorized Name & Signature:

  Sign