C.V.

Ramos Avenue, Taculing, Bacolod City

Tel. (034) 488-7777, local 465,Fax: (034) 433-2255
bacolodadventist@[Link]

ELECTRICAL WORK PERMIT

Project Name: EW Permit No:
Issue Date :
Location:
CONTRACTOR : AREA OF W ORK
/ SUPERVISOR TO BE FILLED BY

WORK STARTING DATE : WORK ENDING DATE TIME

DESCRIPTION OF THE W ORK
YES NO N/A YES NO N/A
Live work required Connected to ground/earth
Remote control isolated Lock Out/Tag Out (LOTO) in place
Warning signs & barriers erected Suitable access/egress provided/available
PPE required Other hazards
WORK EQUIPMENT:
Associated Work permit: WAH No.: HW Permit No: Confined Space Work Permit No.:
Supervisor: Signature: Date: Time:
Safety Officer: Signature: Date: Time:
CONTRACTOR

INDIVIDUAL PROTECTION EQUIPMENT (Please check all applicable):

☐Helmet ☐Hearing Protectors ☐Gas Mask ☐ Dielectric Gloves ☐ Safety Gloves
/

☐Welder’s Helmet ☐Emergency Respirator ☐Safety Shoes ☐ Rubber Safety Boots ☐ Safety Glasses
ENGINEERING WORK SUPERVISORTO BE FILLED BY CONTRACTOR

☐Welder’s Apron ☐Protective Goggles ☐Anti-Dust Overalls ☐ W elders Breeches ☐ H2S Mask
☐Work Clothes ☐Safety Belts ☐Dielectric Boots ☐ Safety Harness ☐ Double Safety Harness
☐Dust Mask ☐ ☐ ☐ ☐ __________

Additional Safety Precautions:

Special Instructions to be followed in case of associated work permits (Hot, Cold, Confined Space):

The Equipment and/or location where the work is to be done has been inspected and the work is safe to do? ☐ YES
☐ NO Competent
Electrical person Signature: Date Time

Supervisor / Manager Signature : Date Time

Safety Officer: Signature: Date: Time:

PERMIT APPROVAL
DEPARTMENT TO BE FILLED BY SAFETY AND

This permit is issued subject to the terms and conditions stated above.

Safety Officer Signature : Date Time

Safety and Security
Department Manager: Signature: Date: Time:

Daily Endorsement (if task exceeds 1 day Daily Endorsement by Authorized Manager/ Hospital Safety Officer) is required.

Day 2 Day 3 Day 4 Day 5 Day 6

COMPLETION OF WORK
DEPARTMENT / MANGEMENT
BY ENGG

I hereby confirm and declare that the work has been completed in accordance to this permit and all equipment have been returned to
service, safety signs have been removed, temporary earthling connections have been removed and the Site restored to safe and tidy
SECURITY

conditions.
TO BE FILLED

Project Safety Officer: Signature: Date: Time:

Competent Electrical Person : Signature: Date: Time:

Department Manager: Signature: Date: Time: