GENERAL WORK PERMIT Control no.

:
This permit authorizes specific work to be undertaken in specific location for a set of duration
Work cannot start until an authorized Permit Issuer and Permit Authorizer have signed this permit
All section must be completed or crossed out if not relevant
The site authorized Permit Issuer is to complete all sections unless otherwise stated on this form
1. Job Details
Job Location: Date:
Equipment to be worked on:
Job supervisor's name: Mobile no.
Describe the job and its scope:

Approximately how many people will work on this job?

List the main equipment to be use on this job (Include any specific Hot Work Equipment)

I have reviewed and accepted the JPT risk assessment and methodology YES
2. Other permits required?
Working at Heights Hot Work Confined Space Excavation
Working Near Water Lifting High voltage
3. Isolation Officer(s) to complete
Electrical Isolations
Equipment Ref. No. Where Isolated Lock Tag Tested (yes/
Signature
(yes/ no) no)

Non- Electrical Isolations

Equipment/ Energy Type Lock Tag Tested (yes/
Where Isolated Signature
source (hose, valve, etc) (yes/ no) no)

Are there any potential residual energy sources? If yes, record in section 5 YES/ NA
4. Is hot work required? If yes, complete this section, If no cross out this section and go to section 5
Is a Fire Watch required? (fire watch should stay at a job for at least 30 minutes after job completion) YES/ NA
Is atmospheric testing required? (if yes complete below section): Initial test results: LEL =… YES/ NA
Why is atmospheric testing required?
Where should the monitor be place? YES/ NA
Will testing be continuous? (mandatory for hot works for confined spaces)
List fire extinguishing equipment required at the job site in section 5
List of additional hazards or controls(PPE, barriers, etc) for hot work in section 5
Does the hot work involve: Confined Space Explosives Pipelines Flamables? (circle)
YES/ NA
iIf yes a second hot work permit issuers or senior manager's signature and date/time is required in section 6
5. Hazards and controls (In addition to those documented on the Job Planning Tool/Risk assessment)
Hazards Controls By Who

6. Permit Issuer, Permit Authorizer and Permit Receiver(Worker's Supervisor) to complete (circle)
Permit Issuer:
Job site: Has been visited by me. I have discussed the job with the permit authorizer YES
High Hazard Checklist Has been reviewed to insure I have considered all hazards and controls YES
Isolation Points: Have been locked, tested and tagged (if required) as per section 3 YES/ NA
Significant Hazards: Have been highlighted on this permit and discussed with the permit authorizer YES
Issued: This permit is now issued to the permit authorizer YES
Name: Signature: Date: Time:
Second Hot Work Permit Issuers signature (from section 4) if required:
Job Supervisor (Permit Authorizer)
Have been reviewed, discuss with the permit issuer(s) and accepted (with
Permit(s): YES
any change)
Job risk assessment Have been reviewed, discuss with the worker's supervisor at the job site
YES
and methodology: and been accepted (with any changes)
of this and other attached permit have been discussed with the worker's
Conditions: YES
supervisor
of this and other attached permit have been discussed with the worker's
Significant Hazards: YES
supervisor and highlighted for transferring to the LST form
The worker's supervisor has been shown where workers shall attach their
Isolations YES
personal locks and tags

Have been attached to this permit and are: (insert document names and reference numbers)
Permits:
Documents: YES/ NA
Other:
E.g. JPT; Plans; Diagrams; Others)

The permit receiver is now authorized to begin work provided the controls documented in this permit are
complied with

Name and Signature Date and Time

This permit only valid between: am / pm and: am / pm
Permit Receiver:
Isolations: All workers will be shown where to lock isolations and will do so prior to starting YES
Conditions: Have been read and understood YES
Significant Hazards: Have been transferred to the LST and will be discussed with all workers YES
Competence: All workers are competent in the work they will be allocated YES
Equipment: All equipment will be appropriate and in good condition with all guard in place YES
Changes: The permit authorizer will be notified of any new workers or changes in the job YES
The permit and associated documents shall be kept in close proximity to the job
Accessibility: YES
and accessible to all personnel.
By signing this permit I agree to abide by all of its conditions

Name and Signature Date: Time:

7. Testing of equipment during the job. (Isolation Officer to complete) (circle)
If equipment has to be re-energized during the job (e.g. for testing purposes), the following must be
completed to make the job and area safe. The Isolation officer must initial each action when completed.
Equipment to be re-energized has been identified YES
All equipment and tools have been moved away from the equipment to be re-energized YES
All people near the work area have been informed of the re-energization YES
Unnecessary people have been moved away from the area YES
Equipment guard that do not interfere with testing have been re-installed YES
All locks and tags have been removed YES
The equipment has been re-energized YES
After testing, the isolation will be re-installed and the job continued or if the job is complete, go to section 8
8. Permit Hand-back (Worker Supervisor to complete)
Locks and Tags Have all have been removed YES
Waste and Materials Have all been removed YES
Machine Guards Have all been re-installed YES
The job: has / has not been completed and is: safe / not safe to return to service (circle)

Name and Signature Date: Time: