COLD WORK PERMIT
Work Permit No. Prepared Date:
Work Location / Area:
Supervisor Name: Contractor/Subcontractor:
Expected Date From To Task Description:
Work / Task
Duration Time From To
Manning Total HSE Supv. Workers Others
Plan
Work Type: General Work, Lifting Work, Working at Height, Scaffolding Works, Excavation, Open Flame, Others________________________
SAFETY CHECKLIST Yes No N/A Remarks
Emergency contact numbers posted?
Toolbox talk / meeting conducted before work?
Safety barricade and signage required?
Tools and equipment in good condition?
Clear access/egress provided?
Proper working platform provided?
Internal training provided? (Induction, Confined Space, Fire watchman, etc.)
Third party certificate required? (for scaffolders, riggers, operators)
Lockout Tagout (LOTO) required?
Sufficient illumination provided? (indoors or night work)
Correct & adequate PPE provided?
Emergency / rescue equipment, first-aider, nurse at site?
Hazards identification required? (supporting document) if YES, please check below form
Gas testing required? if YES, please check below form
Repeated / continuous gas monitoring required? if YES, please check additional form
PPE Required: Safety Helmet, Safety Glass, Safety Shoes, Gloves ( Cotton, Leather, PVC), Full Body Harness, Face Shield,
Chemical/Fire Retardant Clothing, Others ___________________________________________________________________________________
Hazards Identification
Is hazards identification required? (if Yes, attach it on this permit)
Job Safety Analysis (JSA), Risk Assessment, Method Statement, Any other required work permit ___________________________________
Required Control Measure / Action
Other precautions / actions required:
Pre Construction Meeting (PCM), Toolbox Meeting (TBM), Gas Monitoring, Others ______________________________________________
GAS TEST (only Certified Gas Tester shall perform Gas Tests)
Date:
Gas Tester Flammability Oxygen H2S CO
Time Remarks
Badge No. Signature <1% 23.5%<O2>19.5% < 1 ppm < 25 ppm
APPROVAL / CONFIRMATION
Permit Permit Receiver: Permit Issuer:
Status Badge No. Certificate No. Signature Badge No. Certificate No. Signature
Open
This permit is extended: Date: ________________________________________ Time: __________________________________________________
Extended
This permit is closed: Date: ___________________________________________ Time: __________________________________________________
I HAVE INSPECTED THE WORK SITE AND CONFIRMED THAT SAFE AND SOUND CONDITION IS IN PLACE
Closed
