safeworkpmits

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Health & Safety Awareness Training:

Safe Permits to Work:

Safe

Permits to

Work

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Safe Permits to WorkSafe Permits to Work• An introduction for Managers,

Appointed Persons, Supervisors and persons who may have responsibility to issue Safe Permits To Work to, Employees and Contractors

Risk

Method

Control

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Safe Permits to WorkSafe Permits to Work

Why are we here?

The company requires the evaluation of hazardous,Non routine jobs for which there are no Safe Task Proceduresor approved Task Safety Plans.

Certain tasks always require that a Safe Permit to Work be issued by a qualified individual. In our case the Appointed Person

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Goals and Objectives:

At the end of this session you will:

- be familiar with jobs requiring safe work permits.

- be familiar with the Safe Permit to Work system.

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WE DON’T WANT YOU OR US TO END UP LIKE THIS

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Responsibilities: Appointed Responsibilities: Appointed Persons.Persons.

• Duties which include:Duties which include:

• Ensuring the place of work is securedEnsuring the place of work is secured• from unauthorised access.from unauthorised access.• Making full and proper use of all safety Making full and proper use of all safety

devices and guarding equipment at all devices and guarding equipment at all times.times.

• Reporting all accidents, dangerous Reporting all accidents, dangerous occurrences and near misses.occurrences and near misses.

• Ensuring that work equipment is only Ensuring that work equipment is only used for the purpose that it was designed used for the purpose that it was designed to be suitable for. (including privately to be suitable for. (including privately owned tools).owned tools).

• Reporting any safety concerns in relation Reporting any safety concerns in relation to work equipment or the working to work equipment or the working environment to management environment to management immediately.immediately.

• Only using company registered ladders Only using company registered ladders and steps, unless written authority has and steps, unless written authority has been obtained from the client. been obtained from the client.

• Purchasing, using, transporting or Purchasing, using, transporting or disposal of COSHH controlled disposal of COSHH controlled substances in accordance with company substances in accordance with company procedures.procedures.

• Adhering to any instructions specified in Adhering to any instructions specified in method statements, risk assessments or method statements, risk assessments or Permit to WorkPermit to Work issued for that task. issued for that task.

• Reporting unsafe working Reporting unsafe working practices/procedures used by other practices/procedures used by other contractors/sub contractors.contractors/sub contractors.

• Reporting any problems or losses of Reporting any problems or losses of items of PPE.items of PPE.

• Ensuring first aid boxes issued are kept Ensuring first aid boxes issued are kept stocked and available for use.stocked and available for use.

• Reporting any health hazards, e.g. birds Reporting any health hazards, e.g. birds rats, mice etc.rats, mice etc.

• Notifying management of any particular Notifying management of any particular health or welfare concerns they may health or welfare concerns they may have by completion of a Risk/Hazard have by completion of a Risk/Hazard Alert form or by contact direct with Alert form or by contact direct with management if situation is deemed management if situation is deemed urgent.urgent.

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Cutting / WeldingPermit

Location: Job No.

Date: Job No.


Location: Job No.

Date: Job No.

Confined Space Entry Permit

Location and description of confined space:Reason for entry:Permit issued to:Supervisor’s Name:Attendant’s name:Permit issuer’s name:% oxygen: % lower explosive limit: ppm CO: H2S:

Requirements

Emergency Rescuer yes noContinuous Gas Monitor yes noBarrier for ground openings yes noWarning Signs yes no



Requirements


Safe Work Permit Permit #

Type: (hot work, confined space, line break, etc..... location:

Valid __/___/___ ____ __/___/___ ____ Issued to: From: M D Y time to M D Y time

Work Description: ____________________________________________________________________________ Supervisor’s Signature Print name________________________________________________________________________________________ Work Order No.

Atm Combustible vapors or gases (<10%) Oxygen Concentration (>19.5% & <21%) Toxic Material ConcentrationTests

Precautions Always Required:


Type: (hot work, confined space, line break, etc..... location:



Atm Combustible vapors or gases (<10%) Oxygen Concentration (>19.5% & <21%) Toxic Material ConcentrationTests


There are various documents which are called“safe permits to work.”

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Location: Job No.

Date: Job No.

Location & Building: Floor

Nature of Job:

Welder’s Name:

The above location has been examined. The precautions checkedon the reverse of this card have been taken to prevent fire.Permission is granted for this work.

Permit Date: Time:Expires AM

PM


Location: Job No.

Date: Job No.


Nature of Job:

Welder’s Name:



PM

The Hot Work Permit is a formof Safe Work Permit issued bythe Appointed Person,or other responsible person.

This permit is required for allsituations which may result infires or explosions.

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CAUTIONConfined Space

Keep Out !

The “Confined Space EntryPermit” is another form ofsafe permit to work, regulatingentry into pits, tanks, and vessels and

other confined spaces.



Requirements

Emergency Rescuer yes noContinuous Gas Monitor yes noBarrier for ground openings yes noWarning Signs yes noSafety Harness with life line yes noTripod / Hoist / Pulley yes no



Requirements

Emergency Rescuer yes noContinuous Gas Monitor yes noBarrier for ground openings yes noWarning Signs yes noSafety Harness with life line yes noTripod / Hoist / Pulley yes no

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Safe Permits to WorkSafe Permits to WorkCutting / WeldingPermit

Location: Job No.

Date: Job No.


Location: Job No.

Date: Job No.



Requirements




Requirements


Confined Space Entry Permits, Hot Work Permitsand others will be discussed in detail later on.

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Safe Permits to WorkSafe Permits to WorkSafe Work Permit Permit #

Type: (hot work, confined space, line break, etc.... location:



Atm Combustible vapours or gases (<10%) Oxygen Concentration (>19.5% & <21%) Toxic Material ConcentrationTests






Atm Combustible vapours or gases (<10%) Oxygen Concentration (>19.5% & <21%) Toxic Material ConcentrationTests


The objective of the Safe Permit to Work system is toidentify hazards associated with a non routine job, andto develop precautions required to control each hazardidentified.

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Let’s begin with alook at the hazardsassociated withspecific jobs, andexamine how Safe Permits to Work can help to preventthem from causingdamage or injury.

Risk Assessments

Method Statements

Control Documents

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Something with the Potential

For Causing Harm (ie Injury, Damage)

Risk Assessment. What is a hazard?

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Risk Assessment. What is likelihood or probability?

The likelihood that the harm from the particular hazard is

realised.

ie AN EXPRESSION OF POSSIBLE LOSS IN TERMS OF SEVERITY AND PROBABILITY

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Method StatementsMethod Statements

• ‘Generic’ statements can be used so long as they are modified to be specific

• Hand written or hand amended is perfectly satisfactory

• They should be job specific to the job in hand

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Safe Permits to WorkSafe Permits to WorkExamples of tasks requiring permits are:

1. Hot Work - the use of open flame, oxyacetylene burning, tar kettles, etc...., and the use of portable spark or heat producing equipment in flammable storage or handling areas.2. High Voltage work.3. Confined Space Entry4. Excavations5. Hilti Guns.6. Whenever required by existing company or contractor procedures or required in the contractor’s Project Safety Plan.7. Use of internal combustion engines, or vehicles with internal combustion engines inside company buildings.8. Use of company owned equipment, such as personnel lifts, fork trucks, vehicles, etc., by employees of a contractor.

This list is not exhaustive!

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Safe Permits to Work Safe Permits to Work Excavations can result in:

head Injuries from materialsfalling from overhead surfaces,

rupture of high pressure hydrauliclines used on backhoes, shovels,and drills.

excessive noise from concretebreaking and cutting equipment,

and collapse of excavation walls and piles due to poorly secured soil, suddenweather changes, or other factors.

Permits are written to ensure that necessary equipment is present and ingood working order.

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Safe Permits to WorkSafe Permits to WorkExcavations :

Poorly planned excavations can result in damage to underground services, such aselectrical lines, natural gas lines, watersewers and drains.

The consequence of damaged utility servicesis often complete shutdown of operationsresulting in major business losses.

Permits are written to protect the employee and prevent damage to underground equipment and services.

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Excavations may expose hazardous materials, which have leaked and arecontaminating the soil.

Permits ensure that procedures to protect workers from exposure to toxic substances have been identified and for the protection of the environment.

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Safe Permits to Work Safe Permits to Work

Use of Hilti Type Guns.

Permits are issued to ensureprocedures are followed thatprevent injury to users and fellow employees.

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Safe Permits to WorkSafe Permits to WorkInternal combustion engines produce poisonous gasessuch as carbon monoxide, and oxides of nitrogen.

Permits ensure that procedures are followed that will prevent equipment emissions from contaminating air inside buildings and confined spaces.

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Unauthorized use of companyequipment can result in lostproduction and injury to untrainedoperators.

Permits prevent company equipmentfrom being taken by contractorswithout the permission of management,and require verification of equipment Operator training.

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Work which ordinarily does not require safe work permits may be included at the discretion of the :

The Appointed Person.Safety Representative.The Contractor.

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Following are examples of situations which may requirediscretionary safe work permits.

There could be many others:

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Movement oflarge pieces of equipment,especially while other personnelare working nearby, can resultin employee injury.

Permits may be issued to ensurethe use of procedures that willprevent employee injury from falling material, or being struck by equipment. (LOLER Regulations)

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Abandoned tanks, pipe lines,drums, and vessels may containhazardous vapors and gases.

Permits may be issued to preventtoxic or corrosive exposures to workerswhen working on abandonedequipment, complementing hot workand confined space permits.

?

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Many construction processescreate noise levels high enoughto cause hearing loss.

Permit requirements may be issuedto reduce noise to acceptable limits,or to provide both construction andother employees with requiredhearing protection.

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Boilers, high pressurevessels, tanks, etccan undergo sudden failureresulting in disastrousconsequences.

Permits may be issued requiringprecautions and equipment toprevent system failures notcovered by safe job proceduresor project safety plans.

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Safe Permits to Work

Safe Permits to Work

Permits may be requiredwhere the consequenceof non-compliance withfall protection requirementsis severe, or where droppedmaterials may endangerother workers below:

i.e. working over water or working at height.

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Permits are requiredbefore work begins nearenergized lines which cannotbe shut off if there is dangerof fire, shock or electrocution.

Electricity At Work Regulations

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CAUTION

“Safe Permit to Work Required!”

Hazardous Materials!

Confined Space!

High Pressure Gas Mains!

High Voltage!Permits are mandatory where signs are posted which require them.

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Permits are issued:

- for a specific date and time range,- for a specific job,- and to specific individuals.

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-------------------------------------------------------------------------------------------------------------------------------------------------------------------Work Description: ____________________________________________________________________________ Supervisor’s Signature Print name________________________________________________________________________________________ Work Order No.

Atm. Combustible Vapors or gases (<10%) Oxygen Concentration ( >19.5% & < 21%) Toxic Material ConcentrationTests

Permit Issued by: _________________________/____/___ Work Area Manager Approval _______________/___/__


-------------------------------------------------------------------------------------------------------------------------------------------------------------------Work Description: ____________________________________________________________________________ Supervisor’s Signature Print name________________________________________________________________________________________ Work Order No.

Atm. Combustible Vapors or gases (<10%) Oxygen Concentration ( >19.5% & < 21%) Toxic Material ConcentrationTests

Permit Issued by: _________________________/____/___ Work Area Manager Approval _______________/___/__

Permits must be reviewed and signed by:the Appointed Person/Safety Representative

issuing the permit.- the workers’ supervisor,- affected workers,- and the work area manager.

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Safe Work Permit----------------------------------------------------------------------

Precautions Always required:

o Emergency procedures review by:o Emergency equipment & location review by:o Area inherent hazards review by:o Material Safety Data Sheets review by:

Safe Work Permit----------------------------------------------------------------------

Precautions Always required:

o Emergency procedures review by:o Emergency equipment & location review by:o Area inherent hazards review by:o Material Safety Data Sheets review by:

Workers must be informed of required emergency procedures, locationand operation of emergency equipment, and area inherent hazards.(Site briefing or similar).

Material Safety Data Sheets must be supplied and specialprecautions reviewed with workers and their supervisors.

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Safe Permit to Work ----------------------------------------------------------------------

Special Precautions Required:

o Buddy System o Sprinklers in Serviceo Cleaning of _________ o Purging of ________o Remove materials from ___________________o Piping o Drain o Disconnect o Blank off / Cappedo Clean o Ventilateo Remove combustibles from other side of wall.o Floor Swept Clean of Combustibleso Clean area within 10m. o Wet down floor.o Adjacent areas: __________________________o Cover floor with: __________________________o Non-combustible Tarpaulins or Metal Shields Over:o Electrical Switches or Valves off, locked-out, and Tagged:o Electrical Grounding of: ________________________o Atmosphere monitored during work for: ____________ periodically: __________ continuously: __________o Safety Monitor(s) present from _________ to _________o Fire Watch Present during work and for 30 minutes after...o Respirator to be worn____ or be readily available ___

Safe Permit to Work ----------------------------------------------------------------------

Special Precautions Required:

o Buddy System o Sprinklers in Serviceo Cleaning of _________ o Purging of ________o Remove materials from ___________________o Piping o Drain o Disconnect o Blank off / Cappedo Clean o Ventilateo Remove combustibles from other side of wall.o Floor Swept Clean of Combustibleso Clean area within 10m. o Wet down floor.o Adjacent areas: __________________________o Cover floor with: __________________________o Non-combustible Tarpaulins or Metal Shields Over:o Electrical Switches or Valves off, locked-out, and Tagged:o Electrical Grounding of: ________________________o Atmosphere monitored during work for: ____________ periodically: __________ continuously: __________o Safety Monitor(s) present from _________ to _________o Fire Watch Present during work and for 30 minutes after...o Respirator to be worn____ or be readily available ___

Required special precautionsmust be clearly indicated andcommunicated to workers,and their supervision.

It is the safety representative’sresponsibility to determine ifand when special measuresare required.

Permits differ from company to company

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Safe Work Permit----------------------------------------------------------------------

Safety Equipment Required

o safety glasseso hard hato face shieldo safety shoeso fire extinguishers - type ___ #___ size ___o fire hoseo supplementary illuminationo warning signso barricadeso non-sparking toolso explosion proof equipmento safety harnesso life lineo tripod emergency escape unito 2-way radio or phoneo respiratorso impervious gloveso protective clothing _____________________o mechanical ventilationo shower & eyewasho self contained breathing apparatuso ground fault circuit interruptero ladder / lift / scaffoldo other________________________________

Safe Work Permit----------------------------------------------------------------------

Safety Equipment Required

o safety glasseso hard hato face shieldo safety shoeso fire extinguishers - type ___ #___ size ___o fire hoseo supplementary illuminationo warning signso barricadeso non-sparking toolso explosion proof equipmento safety harnesso life lineo tripod emergency escape unito 2-way radio or phoneo respiratorso impervious gloveso protective clothing _____________________o mechanical ventilationo shower & eyewasho self contained breathing apparatuso ground fault circuit interruptero ladder / lift / scaffoldo other________________________________

Personal protective equipmentand other safety equipment requiredis specified.

For each hazard present at the worksite, the safety representative mustspecify a hazard control.

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The Law

• Health & Safety at Work etc Act.

• Electricity at Work Regulations.

• Confined Spaces Regulations.• Construction Regulations.• Management of Health, Safety,

& Welfare Regulations.• Working at Height Regulations.• PUWER & LOLER

Regulations.

• This list is not exhaustive

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Flow Chart

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CAUTIONConfined Space

Keep Out !

Permit-Required Specified Confined

Spaces

• Confined Space Regulations:

• A Permit-Required Specified Confined Space is a space that has a foreseeable risk of:

• One or more of the following characteristics:

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• Foreseeable risk of fire or explosion

• Foreseeable risk of gas, fume or vapour.

• Foreseeable risk of free flowing solids that would restrict access to respirable air.

• Foreseeable risk of an increase in body temperature that may cause asphyxiation.

• Foreseeable risk of a rise in fluids.

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Complete Entry Permit Form

• Permit must be correctly and completely filled out prior to entry.

• Permit must be activated by Entry Supervisor’s signature to be valid.

• No entry is allowed without a valid permit.

• Permits are valid for up to 12 hours.

• When work is completed, permit and toolbox form should be returned to safety.

• Cancelled permits must be kept on file for at least one year.

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High Voltage Permit

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Hot Work PermitsHot Work Permits

Examples of hot work are:

weldingburningbrazingpropane solderingoxyacetylene cuttinggrinding ferrous metals

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Location: Job No.

Date: Job No.


Nature of Job:

Welder’s Name:



PM


Location: Job No.

Date: Job No.


Nature of Job:

Welder’s Name:



PM

Permits are issued for thespecific job being done,

And

For a specific time period, thetime period is usually for theworking shift,

But may neverexceed twenty-four hours.

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Necessary PrecautionsO Sprinklers are in service.O Cutting and welding equipment in good repair.

Precautions within 35 ft. (10 m.) of work.O Floors swept clean of combustibles.O Combustible floors wet down, covered with damp sand or fire-resistive sheets.O Flammable liquids removed; other combustibles, if not removed protected with fire-resistive tarpaulins or metal shields. O Explosive atmosphere in area eliminated.O All wall and floor openings covered.O Fire-resistive tarpaulins suspended beneath work.

Work on Walls or CeilingsO Construction is noncombustible and without combustible covering or isolation.O Combustibles moved away from other side of wall.

Work on Enclosed EquipmentO Enclosed equipment cleaned of all combustibles.O Containers purged of flammable liquids.

Fire WatchO Fire watch will be provided during and for at least 30 minutes after work, and during any coffee or lunch breaks.O Fire watch is supplied with suitable extinguishers, or charged small hose.

O Fire watch is trained in use of this equipment and in sounding alarm.

Necessary PrecautionsO Sprinklers are in service.O Cutting and welding equipment in good repair.

Precautions within 35 ft. (10 m.) of work.O Floors swept clean of combustibles.O Combustible floors wet down, covered with damp sand or fire-resistive sheets.O Flammable liquids removed; other combustibles, if not removed protected with fire-resistive tarpaulins or metal shields. O Explosive atmosphere in area eliminated.O All wall and floor openings covered.O Fire-resistive tarpaulins suspended beneath work.



Fire WatchO Fire watch will be provided during and for at least 30 minutes after work, and during any coffee or lunch breaks.O Fire watch is supplied with suitable extinguishers, or charged small hose.

O Fire watch is trained in use of this equipment and in sounding alarm.

The Fire Marshal, SafetyEngineer, MaintenanceManager or Appointed Person has the responsibilityto verify that all necessaryprecautions have been taken atthe worksite.

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Necessary Precautions

O Sprinklers are in service.


O Sprinklers are in service.

Welding and other hot work have been found to be highranking causes of industrial fires. Sprinkler systems mustremain in service in the hot work area, unless specificallyapproved by the Fire Marshal, Safety Engineer,or Maintenance Manager.

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O Cutting and welding equipment in good repair.


O Cutting and welding equipment in good repair.

Gas hoses, backflow preventors, fire resistive tarpaulins,curtains and other cutting and welding equipment must be ingood repair before the permit is issued.

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Hot Work PermitsHot Work PermitsNecessary Precautions Precautions within 35 ft. (10 m.) of work.O Floors swept clean of combustibles.O Combustible floors wet down, covered with damp sand or fire-resistive sheets.O Flammable liquids removed; other combustibles, if not removed protected with fire-resistive tarpaulins or metal shields. O Explosive atmosphere in area eliminated.O All wall and floor openings covered.O Fire-resistive tarpaulins suspended beneath work.



Necessary Precautions Precautions within 35 ft. (10 m.) of work.O Floors swept clean of combustibles.O Combustible floors wet down, covered with damp sand or fire-resistive sheets.O Flammable liquids removed; other combustibles, if not removed protected with fire-resistive tarpaulins or metal shields. O Explosive atmosphere in area eliminated.O All wall and floor openings covered.O Fire-resistive tarpaulins suspended beneath work.



Anything that can burn must be removed from the immediatework area.

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Hot Work PermitsHot Work PermitsNecessary Precautions

Fire WatchO Fire watch will be provided during and for at least 30 minutes after work, and during any coffee or lunch breaks.O Fire watch is supplied with suitable extinguishers, or charged small hose.O Fire watch is trained in use of this equipment and in sounding alarm.


Fire WatchO Fire watch will be provided during and for at least 30 minutes after work, and during any coffee or lunch breaks.O Fire watch is supplied with suitable extinguishers, or charged small hose.O Fire watch is trained in use of this equipment and in sounding alarm.

Fire Watch Personnel maynot do other jobs whichdetract from their primaryresponsibility.

Fire Watch Personnel must be trained to use fire extinguishmentmedia provided.

Fire Watch Personnel must be aware of how to report emergencies,and in emergency evacuation procedures.

Fire Watch Personnel must be identified and their qualifications verified,before permits are issued.

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Final Checkup By Welder

Work area and all adjacent areas to which sparks and heat might havespread (such as floors above and below and on opposite side of walls) were inspected after the work was completed and were found firesafe.

Signed: After signing, return to person who issued it.

Final Checkup By Welder

Work area and all adjacent areas to which sparks and heat might havespread (such as floors above and below and on opposite side of walls) were inspected after the work was completed and were found firesafe.

Signed: After signing, return to person who issued it.

Before leaving the area for the day, verify that no smolderingfires have developed within walls, cracks in floors, or inceiling areas where you have been working. Return thework permit to the person who issued it within 30 minutes of job completion,so that they may complete any necessary job follow-up.

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Lifting Operations & LiftingEquipment .

• Employer to Ensure :• work planned.• records kept.• trained workforce• appointed persons• lift supervisors.• equipment suitable.• “ maintained.• Employees follow

safe systems.

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Safe Dig Permit. Safe Dig Permit.

Safe Work Permit----------------------------------------------------------------------

EXCAVATION PRECAUTIONS REQUIRED:

o Underground Utility Hazard Reviewo Soil Excavation Reviewedo Underground Utility Stakeout Performedo Excavation cut back walls reinforcedo Means of exiting.

Safe Work Permit----------------------------------------------------------------------

EXCAVATION PRECAUTIONS REQUIRED:

o Underground Utility Hazard Reviewo Soil Excavation Reviewedo Underground Utility Stakeout Performedo Excavation cut back walls reinforcedo Means of exiting.

The safety representative must verifythat all underground utilities havebeen located and staked out by the use of Plans, Drawings etc, and by the use of trainedpersons using Cable Avoidance Tools.

Provisions must be made to barricade the open trench, preventcollapse of trench walls, provideemployees with a means of exit,reroute ground water, and all otherrequirements of excavating.

If soil is contaminated, the safetyrepresentative will ask for a writtenhealth and safety plan.

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Safe Permits to Work - SUMMARYSafe Permits to Work - SUMMARY- Hot work, Confined Space Entry, Excavations, High Voltage work,,

use of Internal combustion engines inside of buildings,use of company owned or leased equipment, and areas where“Safe Permit to Work Required” signs are posted always requirea safe work permit.

- Other safe permits to work may be required at the discretionof the Appointed person, Safety Representative, or the Contractor.

- Permits will be issued by a qualified Appointed person.

- Permits are issued to specific persons for a specific timeperiod and for a specific job.

Permits must be signed at the time issued by the Appointed Personsafety supervisor, affected workers, and the manager of the area inwhich work is being done.

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Where to Get Help?

• Your Appointed person / supervisor may be responsible for providing equipment necessary to comply with Safe Permit to Work requirements.

• The Appointed Person / safety representative is responsible for completing the task hazard analysis and issuing the permit.

• Your Appointed person / supervisor may be responsible for providing equipment necessary to comply with Safe Permit to Work requirements.

• The Appointed Person / safety representative is responsible for completing the task hazard analysis and issuing the permit.

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• Hot work, Confined Space Entry, Excavations, High Voltage work,,• use of Internal combustion engines inside of buildings,• use of company owned or leased equipment, and areas where• “Safe Permit to Work Required” signs are posted always require• a safe work permit.

•- Other safe permits to work may be required at the discretion• of the Appointed person, Safety Representative, • or the Contractor.

•- Permits will be issued by a qualified Appointed person.

•- Permits are issued to specific persons for a specific time• period and for a specific job.

•Permits must be signed at the time issued by the Appointed Person

• safety supervisor, affected workers, and the manager of the area in• which work is being done.•

• Hot work, Confined Space Entry, Excavations, High Voltage work,,• use of Internal combustion engines inside of buildings,• use of company owned or leased equipment, and areas where• “Safe Permit to Work Required” signs are posted always require• a safe work permit.

•- Other safe permits to work may be required at the discretion• of the Appointed person, Safety Representative, • or the Contractor.

•- Permits will be issued by a qualified Appointed person.

•- Permits are issued to specific persons for a specific time• period and for a specific job.

•Permits must be signed at the time issued by the Appointed Person

• safety supervisor, affected workers, and the manager of the area in• which work is being done.•

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2

3

4

Name: Request to the Authorised Person ___________________________________________( Discipline e.g. Foreman

Supervisor) From __________________________________________Job:Detail equipment, plant ________________________________________________________Process or activity upon ________________________________________________________which work is required ________________________________________________________

________________________________________________________Action: Signed: _____________________________ Time _____:______ Date ___/___/___

Position:______________________________________

Detail action and I have read the above request and certify that the above equipment is available, to theprecautions taken degree of safety required by you to perform your work as follows:to achieve safe working ______________________________________________________________________and to avoid perceived ______________________________________________________________________ hazards

__________________________________________________________________________________________________________________________________________________________________________________________________________________________

Action: Signed: _____________________________ Time _____:______ Date ___/___/___Permit Valid until: Time _____:______ Date ___/___/___

Position: _____________________________________

I hereby declare that I accept responsibility for carrying out the work on the equipment/task defined in section (1) above. I will comply with the Safety Rules upon which I have received instructions .

Action: Signed: _____________________________ Time _____:______ Date ___/___/___(Competent Person e.g. Engineer/Electrician)

I hereby declare that I have withdrawn from the equipment/task specified in this permit, and have warned any men who assisted me that it is no longer safe to work on the equipment. All tools, safety devices, earths applied/connected/fixed by my authority have been removed.

Action: Signed: _____________________________ Time _____:______ Date ___/___/___(Competent Person e.g. Engineer/Electrician)

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