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General Work Permit

This document is a general work permit for a routine but high risk procedure. It provides details of the job, location, contractor, hazards present, required permits, isolation measures, required personal protective equipment, supporting documents, and sections for review, authorization and close out signatures. The permit aims to ensure work is performed safely under the specified conditions.

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Greg Genove
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385 views2 pages

General Work Permit

This document is a general work permit for a routine but high risk procedure. It provides details of the job, location, contractor, hazards present, required permits, isolation measures, required personal protective equipment, supporting documents, and sections for review, authorization and close out signatures. The permit aims to ensure work is performed safely under the specified conditions.

Uploaded by

Greg Genove
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

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Client's Engineer's Contractor's


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GENERAL WORK PERMIT: ROUTINE PROCEDURE, HIGH RISK

PERMIT TO WORK NO: DATE:


PROJECT: LOCATION:
CONTRACTOR: CONSULTANT:
EMPLOYER:
EQUIPMENT DESCRIPTION & NO.S:

JOB DESCRIPTION:

PERMITS REQUIRED:  electrical isolation permit  excavation permit  other


 hot work permit  confined space permit  nil required

HAZARDS:  energy sources  moving plant / equipment  hot surfaces


 ground disturbance  working at height  hazardous substances  other
 lifting operations  confined space  environmental

CONTROL MEASURES:

SPECIFIC PPE:  hearing protection  safety harness  dust mask


 hot work clothing  rubber boots  goggles  other
 face shield  gloves _______ (type)  chemical suit

SUPPORTING
 confined space entry cert.  excavation checklist  list of personnel
DOCUMENTS:
 task risk assessment  method statement  drawings  tool box talk record

REVIEW AND AUTHORIZATION:


I, the approving authority, have inspected the work area and hereby confirm it is safe to perform this task under the conditions of
this permit.
Name:………………………………….………….… Signature……………………………………….. Date…………..
……………………...
I, the permit coordinator, have reviewed this permit and supporting doc.s and confirm that they are in compliance with the permit
procedure.
Name:………………………………….………….… Signature……………………………………….. Date…………..
……………………...
I, the performing authority, accept the conditions stipulated in this permit and confirm that all control measures and isolations are in
place.
Name:………………………………….………….… Signature……………………………………….. Date…………..
……………………...

CLOSE OUT:
 THE WORK IS COMPLETE
 THE WORK IS INCOMPLETE AND LEFT IN THE FOLLOWING CONDITION (STATE REASON):

Performing authority:I declare that the work for which this permit was issued has been properly performed, and that the area has
been left in a safe, clean, condition.
Name:………………………………….………….… Signature……………………………………….. Date…………..
……………………...
Approving authority:I have inspected the work area and declare that the work for which this permit was issued has been properly
performed, and that the area has been left in a safe, clean,
Name:………………………………….………….… Signature……………………………………….. Date…………..
……………………...
PTW coordinator:I declare that this permit to work has been closed out as per permit to work procedure and been logged into the
permit to work register under the document control group (DCG)
Name:………………………………….………….… Signature……………………………………….. Date…………..
……………………...

General Work Permit

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