WORK PERMIT FOR WORKING AT HEIGHT

TO BE FILLED BY CONCERNED DEPARTMENT

Concerned Department: _____________________________________________________________

Site Location: _____________________________________________________________

Description and Nature of Work: _____________________________________________________________

Name of the Agency involved: _____________________________________________________________

Validity: From: ______ Hrs. of Date: _________ To: ______ Hrs. of Date: _________

Expected Hazard: _____________________________________________________________

TO BE CHECKED BY EXECUTING DEPARTMENT:

Particulars Yes Not Signature

Required
1. Have Safe Working Platform / Scaffold / Ladder been
provided?
2. Have proper Lighting and Ventilation been provided?

3. Have you ensured that single person is not working?

Name of the persons who are executing the work:
(A) _______________________________________
(B) _______________________________________

4. Have following Personal Protective Equipments been

provided?
Tick the items as applicable.
□ Helmet □ Face Shield □ Hand Gloves □ Goggles
□ Safety Belt □ Safety Shoes □ Air line respirator / Gas Mask
□ Specify others ________________
5. Is nearby area checked and found free from Hazard?

I have personally checked the above arrangements I have personally checked the above arrangements
and found correct. and found correct.
Signature: _______________________ Signature: _______________________

Name: _______________________ Name: _______________________

Date: ___________ Time: ___________ Date: ___________ Time: ___________

In-Charge: (Execution Dept) In-Charge: (Concerned Dept)
RENEWAL OF PERMIT:

All the permit conditions have been re-checked and the permit is renewed.

Date From To Name of I/C Signature of I/C Name of I/C Signature of I/C
(Hrs.) (Hrs.) Execution Dept Execution Dept Concerned Dept Concerned Dept

Note:
1. If the work is to be executed on roof top, authorization by Safety Officer is must.
2. Violation of any of the above precaution will be treated as cancellation of the permit.
3. This permit is not valid in case of emergency. In that case stop the work in safe mode and follow onsite
Emergency Plan.
4. After completion of the work, this permit is to be handed over to Safety department.