W work Order No: ELECTRICALW work Permit No:
Location: _________________ WORK PERMIT
_______________________ Issue Date
_________________________
SUBCONTRACTOR _______________________________ AREA OF W ORK_____________________________________
WORK STARTING DATE TIME WORK ENDING DATE TIME
DESCRIPTION OF THE W ORK
SUBCONTRACTOR
TO BE FILLED BY
YES NO CHK YES NO CHK
Live work required Connected to ground/earth
Remote control isolated Lock Out/Tag Out in place
W warning signs & barriers erected Suitable access/regress provided/available
PPE required Other hazards
WORK EQUIPMENT _______________________________________________________________________________________
Associated W work permit: HOT No.: COLD No.: CONFINED SPACE No.:
Subcontractor receiving Authority Date Time
Subcontractor performing Authority Date Time
INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X):
□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves
□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses
TO BE FILLED BY CONTRACTOR
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask
□ W 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 _________________________________________________ Date Time
Contractor Issuing Authority ___________________________________________________Date ________ Time ________
CLEARANCE
SUBCONTRACTOR
TO BE FILLED BY
I hereby declare that the work is completed, all workers under my control have been withdraw and warned that is no longer safe
to work on the apparatus specified in this Permit of W work and that tools, temporary earthling connections have been removed
and the Site restored to safe conditions.
Subcontractor Performing Authority Date Time
TO BE FILLED BY
I accept that the work is completed/suspended and the Site is restricted to a Safe conditions and the Apparatus is ready for restart
Operating Authority _____________________________________________________________ Date ________ Time ______
Competent Electrical person _____________________________________________________ Date ________ Time
OWNER
_______
