Document Number
Revision Number
Safety Management System 001
Risk Management Page Number
Safe Work Permit Page 1 of 1
I, (Name) _______________________________________ , am required to carry out the work detailed below and request a permit to
cover the following hazards, from the competent/responsible person, to access the following Plan/Area (Indicate with an X which hazards
are applicable)
Area where work is to be carried out: Excavations Permit
Description of work to be carried Out: Electrical Permit
Hot Work Permit
Vehicle Permit
Confined Spaces Permit
Lifting and Rigging
Construction Work
Date and time of commencement Date: Time:
Estimated date and time of completion Date: Time:
Health & safety precautions identified Excavations Electrical Hot Work Vehicle Confined Lifting and Construction
Spaces rigging Work
1. Specific hazards identified during site
inspection
2. All flammable materials and vapours have been
removed.
3. Protective equipment is available and
serviceable
4. Permit holder and assistants have been
instructed what to do in case of an emergency
5. The area is adequately safe
6. Lock out procedure has been followed
7. Clearance between machinery and Powerlines
are according safe working standards
8. From site inspection it would appear that the job
can be safely performed
9. Fire extinguisher available
10. First aider and kit available
11. Correct PPE available and used
12. Is the permit holder in position of a WSWP &
WSOP
13. Other provisions made:
WE ARE SATISFIED THAT THE ABOVE PRECAUTIONS HAVE BEEN TAKEN AND THAT IT SHOULD BE SAFE TO CARRY OUT THE ABOVE MENTIONED WORK
SIGNATURE:
COMPETENT/RESPONSIBLE PERSON NAME: _______________________ ______________________________
DATE: _______________
SIGNATURE:
SAFETY OFFICER NAME: _______________________ ______________________________
DATE: _______________
SIGNATURE:
PERMIT HOLDER NAME: _______________________ ______________________________
DATE: _______________
WE CERTIFIED THAT THE ABOVE JOB HAS BEEN COMPLETED, THE AREA WAS INSPECTED FOR ANY REMAINING HAZARD OR CONDITION AND HAS
BEEN CLEARED AND IS IN A SAFE CONDITION
SIGNATURE:
COMPETENT/RESPONSIBLE PERSON NAME: _______________________ ______________________________
DATE: _______________
SIGNATURE:
SAFETY OFFICER NAME: _______________________ ______________________________
DATE: _______________
SIGNATURE:
PERMIT HOLDER NAME: _______________________ ______________________________
DATE: _______________
