HOT WORK PERMIT

Long Duration □ □
Yes No
Work Permit No: _______________

Work Location
Department
Section
Electrical Isolation Permit No.
No. of Persons working
A. Validity of Permit (Date & Time) From To under the Scope of this permit

B. Job Description:
C. Planning & Assessment:
Yes No N/A
Risk Assessment (HIRA / JSA)
Job Method Statement
E. Equipment / Line: F. Equipment or Line Tag / ID:
Tick in the Appropriate Box
F. Worksite / Equipment Preparation Yes No N/A G. Required PPE:
1. Process Isolation - System Fully Depressurized State (Tank /
Line)
2. Electrical Isolation
□ Safety Helmets □ Safety Shoe □ Safety Goggles □ Face Shield

3. Hydraulic Isolation, if any □ Ear Plug □ Ear Muff □ Cotton Gloves □ □

Leather Gloves Chemical / PVC Gloves □
4. Instrument Isolation (Power / Pnematic) if any
5. Flammable Materials Removed Safety Harness □ Safety Net □ Cover all □ □
Fall Arrest Dust Mask □ Half Mask □ Gas
6. Working @ Height
7. Excavation Works Monitor □ Self Contained Breathing Apparatus □ □ Air Line Rescue Rope
8. Gas Testing Required
9. Traffic Management □ Fire Extinguisher □ Fire Blancket □ Edge Protection (Hand Rail) □ Step Ladder
10. Safety Guards shall be removed
11. Radiation Isolation Tag No…………………………………………. □ Mobile Scaffolding □ Fixed Scaffolding □ Manlift □ Boom Loader □ Mobile Crane
Name of stand by person ………………………………………………..
Signature: ……………………………………………………………………….. □ Barrications & Signages □ Chemical Suit

12. Artificial Lighting Arrangement □ Others___________________________________________________

13. 7. MS / RFS Tag shown in DCS
14. Mechanical Ventilation if Required (i.e Fan, Exhaust) _______________________________________________________________
15. Other Information, If any,

E. Gas Test □ Required □ Not Required

Gas Result
Date & Time ……………………………….
1 2 3 4 Details & Precautions Accepted Level
Time
Oxygen % 19.5 - 22.5
Combustible LEL % 5
Toxic Gas H2S ppm 8
Toxic Gas - CO ppm 25
Name of Gas Tester: ………………………………………………………………………………………… Signature of Gas Tester: ……………………………………………………………………………
I. Fire Watcher Name:……………………………………………….. Signature: …………………………… Mobile No: ………………………………………
J. If the Job is carried out by Contractor, Name of Contracting Company …………………………………………………. Contact Person: …………………………………………………………..
K. Permission granted for work to commence
Job preparations & precautions were well explained in TBT, SOP & JSA, etc., to the Receiver & their System is FULLY SAFE to start the Job: I understand the Job explanation, preparation, precautions to be
Team taken while executing & will inform the issuing authority about
any discrepancies.
Permit Requestor : Permit Issuer (Process Owner): Permit Receiver :
Name: ……………………………………………………………………………………... Name: ……………...………………………………... Name: .......………………………………………………………………...
Signature: ………………………………………………………………………………… Signature: …….……………………………………… Signature: ...…………………………………………………………………
Date & Time: …………………………………………………………………………... Date & Time: ..……………………………………… Date & Time: ...……………………………………………………………

H. Permission granted for the TRIAL RUN

Job preparations & precautions were well explained in TBT, SOP & JSA, etc., to the Receiver & their System is FULLY SAFE to start the Job: I understand the Job explanation, preparation, precautions to be
Team taken while executing & will inform the issuing authority about
any discrepancies.
Permit Requestor : Permit Issuer (Process Owner): Permit Receiver :
Name: ……………………………………………………………………………………... Name: ……………...………………………………... Name: .......………………………………………………………………...
Signature: ………………………………………………………………………………… Signature: …….……………………………………… Signature: ...…………………………………………………………………
Date & Time: …………………………………………………………………………... Date & Time: ..……………………………………… Date & Time: ...……………………………………………………………

M.Permit Handover ⃝ Between Issuers ⃝ Between Requestors ⃝ Between Receivers ⃝ Between Fire Watch
Time: Name
Reliever
Reliever Signaturer
Reliever Mobile No.
N. Extension of Validity
Date Valid up to
Permit Issuer (Process Owner): Requestor Permit Receiver

O. Completion of work P. Site / Equipment Acceptance

Work completed, housekeeping done & checked. ⃝ Permit Cancelled ⃝ Hold ⃝ Permit Closed
Date & Time:…………………………………………… Reason for Hold-up & Time____________________________________________________
Permit Receiver: ………………………….. Permit Requestor: …………………………………. ⃝ Job Resume Date & Time ___________________________________________________
Signature: …………………………………….. Signature: ………………………………………………. Work site checked / equipment taken over back after maintenance.
Electrical Isolation / Tag has been removed.
Permit Issuer (Process Owner): ………………………….....…………………………………..........
Date & Time: ……………………………………......... Signature: ……………………………….........

Q. Monitoring of Job Site (For 1 Hour after Completion of Job) Fire Watch Date:…………………………………………… Time: ………………………………………….
Name: ……………………………………………………………………………………………….
Signature: ……………………………………………… Mobile No.……………………………………..

White Copy: PTW Book (Issuer), Yellow Copy: Receiver, Blue Copy: Permit Requestor
Safety Dept. Contact No.: 056 417 6699 / 02305 2521 First Aider No. 054 785 5786/ 02305 2536
White Copy: PTW Book (Issuer), Yellow Copy: Receiver, Blue Copy: Permit Requestor
Safety Dept. Contact No.: 056 417 6699 / 02305 2521 First Aider No. 054 785 5786/ 02305 2536

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