WORK PERMIT

Time Date

This authorizes Mr.

to perform the hours

following work in

From: hrs Date:

To: _________ hrs Date:

Note : Mark which one is applicable.

YES NO N.A
1. Is the Equipment electrically disconnected?

2. Is the Equipment under Pressure and hot?

3. Has the Equipment been isolated, drained, purged & cold?

4. Is the adjacent area safe for spark & there lie no oil container, wooden planks, waste cloth etc. nearby?

5. Is fire extinguisher / fire hose placed nearby?

6. Is the welding, heating or cutting equipment in safe working order & in safe place?

7. Have the unit affected by this work been notified?

8. Is the equipment electrically by passed to make it run on local?

9. Is the emergency wire pulled when working on conveyor belt?

10. Is safety belt available for work at height?

Inititated by :
Name : _____________________

Department:_____________________

Equipment / Unit handed over after complete preparation.

Authorized by:
Shift Engineer

I understand the precautions to be taken for this job and it is my responsibility to clean up and notify the authorized person
when the job is complete.

Maintenance person

Extended upto: _______________________________ By

Job completed Time

Job incomplete Date

Maintenance person

Job taken over after completion & clean up. Shift Engineer

ALL WORK AREAS ARE NON-SMOKING AREAS