Date

DAILY/WEEKLY WORK PERMIT JSA No

Permit No

Excavation
Nature of Work(Tick as appropriate) Working on Height Electrical Maintenance Confind Space Entry Rigging Others
work

A REQUEST TEAM

1 Name of the Contractor

2 Area & Location

3 Date and time of work start

4 Date and time of work finish

5 Tools and Equipments involved

6 Description of work

Concerned Contractors Work In-Charge Contarctor Safety Representative

Name
Signature
Date
B PREPARATION C SAFETY PRECAUTIONS (Please Tick)

1 Surrounding Area ,Equipment lines,Cables protected/ covered Yes/No 1 Ensure proper approach arrangement

2 Gas Test Monitored Oxygen Level/Explosive gas level(for confind sapce permit) Yes/No 2 Wear Proper PPE's

3 Following Personel Protective Equipment should be used(Tick the required) Yes/No 3 Wear Full Body harness

a Safety Shoe Yes/No 4 Display Warning Sign Boards

b Helmet Yes/No 5 Ensure Good House Keeping before and after the work
c Full Body Harness Yes/No 6 Ensure proper earthing .
d Hand Gloves Yes/No 7 Ensure proper scaffolding/ladder
e Respiratory Protection Yes/No 8 Barrication of area in case of rigging jobs or excavation works
f Ear Protection Yes/No 9 Using certified lifting Machines and tackles
g Eye Protection Yes/No 10 Checked safe condition of hand tools/ Power tools.

4 Has Electrical clearance been given? Yes/No 11 Ensure the Presence of supervisor during excavation/Execution.
5 Has Double Guard Rail been Provided? Yes/No 12 Life Line is provided for height work
6 Has adequete Working Platform been provided? Yes/No Remarks :-

7 Has safety tag provided? Yes/No

8 Has the Fire Extinguisher(IS:13849) provided? Yes/No
9 Employees aware about hazards and safe working practices while working at height. Yes/No
10 Roof Laddera are in use if working on roof Yes/No
11 Yes/No
D Permit is granted and Valid upto: Permit closing out time :

E PERMIT ISSUD BY: F Permit Extension Date:

Name Date Time From: Time TO:

Name Site Engineer : Sign

Sign

PERMIT RECEIVED BY: Safety Officer: Sign

Number of Workman
Name Date
Check Adequate lighting arrgement for night work All
Sign other above requirements are applicable for extension work.