The permit is automatically suspended on activation of the General Alarm or Instruction via Notification Alarm.

HOT WORK PERMIT

WORK PERMIT NUMBER HWP - PERMIT ISSUED TO SUBCONTRACTOR Yes □ No □
DIVISION / SUBCONTRACTOR NAME MANPOWER
1 A TASK DESCRIPTION
Task/Work Description

Location/Area

Validity Period
Work Shift □ Day Shift □ Night Shift
Days Date From To From To
(Working Duration)
Time From To From To
B HAZARD IDENTIFICATION & RISK ASSESSMENT
Description of Possible Hazards □ Work at Height □ Open Flame □ Spatter □ Unauthorized Entry □ Back Pressure □ Combustible Material
□ Flammable Gas □ Flammable Liquid □ Chemicals □ Cables / Hoses □ Isolation □ Consumables
□ Vehicle Movement □ High Noise □ Equipment Hazard □ Spillage □ High Pressure □ High Temperature
□ Others
Attachment required □ HEMP □ Risk Assessment □ Method Statement(MS) □ Drawings □others ______________
C CONTROLS
Required Control measures: Yes No N/A Other Control Measures: Yes No N/A
ORIGINATOR / PERFORMING AUTHORITY

Fall Protection/Safety Access/Work Platform □ □ □ Provision of Fire Extinguisher , Fire Hydrant Hose □ □ □
Grinding Spark Protection Shield in place □ □ □ Power Cables / Hose in good Condition □ □ □
Assignment of Fire Watch and Area free from Combustibles □ □ □ Grinding /Cutting Wheel, other Consumables in Good condition □ □ □
Use of Fire Blanket / Fire Retardant Tarpaulin □ □ □ Ventilation Fans □ □ □
Hard / Soft Barrier □ □ □ Temp/Humidity/Wind Speed within Safe limits □ □ □
Flashback Arrestor for Gas Cylinder □ □ □ Heat Stress Control Measure □ □ □
Trolley for Gas Cylinder and Cylinder Secured with Chain □ □ □ Gas Test (if "Yes" go to D ) □ □ □
Condition of Hoses and Regulator for Gas Cylinder □ □ □ Confined Space Entry (if "Yes" go to F) □ □ □
Adequate lighting □ □ □ Override of HSE Critical devices (if "Yes" go to F) □ □ □
LOTO (Logout/Tagout), if 'Yes' check Isolation work permit □ □ □ Others (________________________________) □ □ □
PPE Required (Check the box if required) ;
Safety Helmet □ □ □ Face shields □ □ □
Safety Goggles □ □ □ Apron, Leg Guard □ □ □
Safety Boots □ □ □ Hood (□ Welding, □ Blasting, □ Others) □ □ □
Glove s(□Cotton, □Leather, □Nitrile, □IR) □ □ □ Chemical/Fire Resistant Clothing □ □ □
Full Body Safety Harness and Double lanyard □ □ □ Others (________________________________) □ □ □
Actions & Other Precautions:

D GAS TEST (If additional gas tests are required, use the Additional Gas Tests Form)
Toxic
Gas Test Parameter Flammable Oxygen
Date Time Name H2S CO Ammonia SO2 Others Remarks
Safe Limits < 1% LEL 23.5%<O2> 19.5% < 10 ppm < 35 ppm < 25 ppm < 2 ppm

Test Results

Test Results

Test Results
2 E CROSS REFERENCES & ACKNOWLEDGMENT F PERMITS & CERTIFICATES REQUIRED
ORIGINATOR/AREA
SUPERVISOR

Other permits in area that Yes □ No □ Details: Other Permits or Certificates Required Yes □ No □
could interfere: [SIMOPS] Confined Space Work Permit Number
Acknowledgement form Electrical Work Permit Number
Other Parties Isolation Certificate Number

3 DESCRIPTION PERFORMING AUTHORITY AREA SUPERVISOR ISSUING AUTHORITY HSE TEAM (AOTC)
I understand and accept the above conditions and precautions and accept I declare that all hazards have been identified and all specified control The Permit and any supplementary certificates have been completed. The For check, Compliance and Record
Acknowledgement responsibility for the work and ensure the persons under my control measures are in place and it safe to carry out the work defined control measures defined are in place.
understand and comply with these conditions and precautions
ISSUE

Name
Sign
Date/Time
CHECK

CANCELATION
EXTENSION

4 PERFORMING AUTHORITY AREA SUPERVISOR ISSUING AUTHORITY HSE TEAM (AOTC)

DATE TIME
NAME SIGN NAME SIGN Name SIGN NAME SIGN
D

□ □
EXTENSION OR CANCELLATION

□ □
□ □
□ □
□ □
□ □
5 DESCRIPTION PERFORMING AUTHORITY AREA SUPERVISOR ISSUING AUTHORITY HSE TEAM (AOTC)
I declare that the work has been properly performed and that the I have inspected the equipment/work area and declare that the work All copies of Permit & any supplementary certificates collected. The control For check, Compliance and Record
Acknowledgement equipment, plant and apparatus affected by the work have been left in a defined in this permit is complete and that the area is clean and safe. measures put in place for this permit have been removed.
safe, clean condition
COMPLETION

Name
Sign
Date/Time
Document Tag: AOTC-IMS-L4-301-F-002 | Rev:01 | Date: 10-01-2021