WORK AT HEIGHT PERMIT

Project Name: Permit No.:

Date: From: To: Duration (Time): From: To:
1. Details of Work:
1.1 Name of Company:
1.2 Location of Work:
1.3 Description of Work:

1.4 Person in Charge (supervisor): No. of Workers:

1.5 Equipment & Tools
to be used:
Unsafe Access/Egress Incomplete Working Platform Fall From Height

2. Hazard Incomplete Guardrails Overloading Working Platform Falling Objects

Considerations
Overreaching Adverse Weather Conditions Unprotected Edges

Additional Hazards to be present: (for further, you may use back side of this page):

Wear Full Body Harness Proper Access/Egress Proper Guard railing

3. Precautions &
Fire Protection Install Toe Boards Complete Working Platform Avoid Overreaching

Additional Precautions to be taken: (for further, you may use back side of this page):

4. Atmospheric Test: Gas test required? Yes No If yes record the results below
Name Time Flammable 0% LEL Oxygen 23.5%-19.5% H2S Signature

Remarks Regular basic PPE, availability of adequate supervision, method of statement, & risk assessment, etc., are mandatory.
Person Authorized Permit Name Position Sign Date
Permit Receiver from Sub-Contractor:
Permit Issuer from HEES:
Tick Permit Statement Person Name Sign Date
Permit date is finished, job is still not Request (Receiver)
finished, Please extend the date of Approved (Issuer)
the Permit Permit extended up to:
Request (Receiver)
Permit is closed, job is completed
Approved (Issuer)
Permit Cancellation:
Cancellation Remarks:
Cancellation Requested By: Authorized By:

HEES-PTW-05, REV-00