LIFTING PERMIT

Safety Requirements to be complied with prior Application of lifting permit :

Permit No: Date : Time :
Are tag line required to support the lift? Yes No
Location / description of work :
Are there any electrical hazards in the area?
Name of lifting supervisor in charge : Signature :
Are the ground condition suitable for completing the lift?
Name
Is thereofcompetent
Crane Operator
Rigger onsite? Signature :

Is thereofAppointed
Name rigger lifting supervisor? Signature :
Are there Provision of signage & Barriers?
Insert load description of lift :
Are there lifting gear inspected properly by user before lifting?
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Are there Crane access in good condition?
Are thereWork
A Safe enough spaceStatement
Method to extend crane outrigger?
(SWMS), Job Safety Analysis (JSA) and/or Safe Work Procedure (SWP) has
been provided and is attached to this ‘work permit’ Yes No
Are the lifting lugs visibly free of defects or damage?

Authorization
Permit Issued To:
(Print name) (Signature) (Date)

Permit Issued By:

(Print name) (Signature) (Date)

Cancellation/completion of permit
Final Sign
Permit Off
cancelled/returned by:
The worksite has been inspected by me at the cancellation/completion
(Print name) of the work at heights and declared safe for
(Signature)
normal operations to resume.

Cancelled/returned at: am/pm On:

(Print name) (Signature) (Date)
Reason for cancellation :

This permit should be prominently displayed at the work site