WORK PERMIT

Permit no: Date

Permit to work for: Propane yard Work

Work at height Handling of chemicals

Electrical installations Installation of new equipment

Confined space LPG Lines / Oil Installation

Hot work Miscellaneous (please specify)

Layout / Plan approved by Safety Dept: Yes No N. A.

If yes Drawing no. ____________________________

Maximum No. of workers to be employed on single Day :- ( Please Fill Names of all Persons On Last Page.)

Permit valid from ______ am/ pm of ______________to _________am/ pm of ____

(Start Date) (End Date)
Permit issued to M/s ……………………………………………………………………..
Address: …………………………………………………………..

Location of work: ………………………………………………………………………..

Description of the job: …………………………………………………………………. .

……………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
Statutory Complinces;

Sr.No. Particulars
1 Method of payment of wages Monthly/weekly/Daily
2 Date/Day Of payment of Wages
3 Pf Code No.
4 Workers Compation Policy No.,
Validity
Name of Insurer & Address
5 Labour License No.

Signature
Verified By
(Human Resources)

Lock Out Tag out (LOTO) system applicable? Yes No

FOLLOWING SAFETY PRECAUTIONS ARE TAKEN CARE OF –
Yes No Not Required

1. All concerned personnel instructed about the nature of work

2. Roof – work ladder provided

3. Safety net provided

4. Scaffolding as per standard provided

5. Access ladder to work / roof provided & properly secured

6. Ladder attendant provided

7. Personal protective Equipment provided (PPE’S)

(Strike out not applicable)

Helmet / Safety shoes / Full body harness / hand gloves / Earplugs / Face shields / safety goggles / Apron /
Respirators
8. Electrical equipment de-energized (LOTO followed)

9. Electrical equipment checked for earthen

10. Portable electrical equipment tested by maintenance Dept.

11. Pipeline / tank drained

12. Line / tank purged

13. Line / tank tested or residual gas / vapors

14. Fire fighting facility provided

15. Proper means of escape available

I will ensure that all the above precautions will be in place.

Head of Signature Permit holder – Contractors Sign

Initiating Dept.& Name & Name-
Date - Time - Date - Time-
_____________________________________________________________________________________
I hereby certify that I have complied with the above and will ensure that all employees engaged by me will follow
safety norms and will take all safety precautions while doing work in your premises. I also declare that I shall be
totally responsible for the safety working of my employees and I will not hold (Company Name) responsible for
any accident and resultant injury to any employees. I understand all instructions told by safety representative &
follow safety rules
Date:…………….. Time:……………….. Name:…………….. Signature:………………..
(Permit Holder – contractor supervisor)
_________________________________________________________________________________________

I have explained the safety precautions to be taken and the work may be started.

……………………………………………………………………………………………………………………

Date: ………… Time:……….. Name: ……………….. Signature:…………

(Safety Representative)
PERMIT CLOSING (After closing of work, the permit to be returned to initiating Dept.)

Before work permit closing permit holder has to check following points

1. Clean the floor after work is finished so that no oil, grease, water traces will not remain
2. Keep all electrical instruments like welding machine, electrical drill & grinder etc. at safe place. Don’t keep
near flammable substances.
3. House keeping for area should be properly maintained & if work is going to continue on next day, all
equipments to be kept properly, especially liquid should be kept in tightly condition.
4. Put all hand gloves, face masks in allocated dust bin only.

I certify that I have completed the work specified in this permit. All my workmen and equipment have been
removed from the vicinity of he above work. I hereby handover the permit or cancellation and for testing &
energizing / putting apparatus back into service whenever applicable.

Date : Time:………….. Name …………………………… Signature:………………

(Permit holder- contractor supervisor)

I confirm that all above instructions of closing permit is completed by permit holder

Signature

Initiating dept
Date- Time-
_______________________________________________________________________________________
Note

1. Work permit is not valid If not authorized by Safety Dept.

2. The contractor and his personnel must follow the safety rules.
3. The work activity should be monitored y competent supervisor.
4. The work permit is valid for period mentioned. Validity can be extended with prior written permission of
initiating dept. safety dept. provided the nature of work & place remain unchanged.
5. Work permit must always be available at site.
6. Safety representative is authorized to stop the work if the safety precautions mentioned in the work permit
or otherwise are not adhered to.

Distribution Of Copies-
I. White Copy- Submit to Main gate
II. Red copy – Retained by Initiating Dept
III. Blue Copy – Retained by Contractor on work location.
  Safety Instructions *

While Working at Height

1. Always use proper safety belt, which should be tied to firm support at the time of
working.
2. Platform scaffolding being used to climb should be adequate strength. Platforms being
used at height must have railing and foot rest to prevent fall of person.
3. While working at height it should be checked that no live electric connection exists in
vicinity.
4. While working on Asbestos roof, roof ladder must be used.

While carrying out hot work (Welding / Gas cutting)

1. Before starting Hot Work, check that no combustible material is lying in the vicinity.
2. Check that adequate Fire fighting appliances and water is available.
3. Use suitable protective equipment such as welding shield hand gloves etc.
4. Never use empty chemical drums or gas cylinders as a platform to stand upon while carrying out Hot
work.
5. If the work is to be carried out at height then depute one person for warning passer-by and watch for
possible fire.
6. After 15 minutes of completion of the job, inspect the work area again for fire and then only leave the
place.

While working on Electrical installation:

1. Before starting any work on electrical installations check that electric supply has been cut off positively.
2. While working on High-tension lines, use protective equipments like electric resistant shoes, gloves, etc.
3. Cautionary board such as “Men at work” must be displayed on respective switchboard till job is
completed.

While working on LPG Yard / LPG pipelines

1. Only flameproof electrical equipments should be used while working on LPG yard.
2. While using hand tools precautions to be taken that no spark is generated during the operation.
3. Security dept. must e informed prior to such an activity.
4. Fire fighting arrangements should be made before the work starts.

While working in confined space:

1. Before starting work in confined space check that the area is free from any explosive /injurious material.
2. Use proper protective equipments such as respirator etc. Person working in the confined space should
were safety belt and person deputed outside should hold lifeline of this belt.
3. If required use electric supply strictly below 24 Volts.
4. Ensure proper ventilation and lighting inside confined space.
5. If work is inside the tank, then ensure that all supply lines to tank are blinded properly. If there are
impellers / agitator in the tank then ensure that they are properly locked
6. Keep one person outside the confined space to render assistance in case of emergency.
7. After ensuring that all working persons in the confined space have came out then only leave the site.