(NAME OF COMPANY)
(LOCATION)
WORK PERMIT
for
HOT WORK
Sl.No.
Work clearance from hrs of date_ To hrs of date (Valid for the shift
unless renewed)
Issued to (Department / Section / Contractor)
Exact Location of work (Area / Unit / Equipment no.
etc)
Description of work
THE FOLLOWING ITEMS SHALL BE CHECKED BEFORE ISSUING THE PERMIT
(Tick mark in the appropriate box. Checklist items marked with asterisk (*) shall be complied by receiver)
Sr Item Done Not Sr Item Done Not
no Reqd. no. Reqd
A General points B For Hot work
1 Equipment / Work Area inspected 1 Proper ventilation and Lighting providing
2 Surrounding area checked, cleaned and 2 Proper means of exit / escape provided
covered
3 Sewers, manholes, CBD etc and hot surfaces 3 Standby personnel provided from Process /
nearby covered Maint / Contractor / Fire / Safety dept.
4 Considered hazard from other operations and 4 Checked for oil and Gas trapped behind the
concerned persons alerted. lining in Equipment
5 Equipment blinded/disconnected / closed / 5* Shield provided against spark
isolated / wedge opened
6 Equipment properly drained and depressurized 6* Portable equipment / nozzles properly
grounded
7 Equipment properly steamed / purged 7* Standby persons provided for entry to
confined space
8 Equipment water flushed
9 Iron sulfide removed / kept wet C For Vehicle Entry
10 Equipment electrically isolated and tagged 1* Spark Arrestor on the mobile equipment /
vide permit no. vehicle provided.
11 Gas test : HCs = %LEL
Toxic gas = ppm, O2 = %
12* Running water hose / Fire extinguisher
provided. Fire water system available.
13* Area cordoned off and Precautionary tags /
Boards provided.
REMARKS:
1. The activity has the following expected residual hazards (Tick the relevant items): Combustible gases
liquids/ Pyrophoric Iron / Corrosive Chemicals / Steam – Condensate / Others
2. Following PPEs to be used in addition to standards PPEs (Helmet, Safety Shoes, Hand gloves, Boiler
suit): Face Shield / Apron / Goggles / Dust Respirator / Fresh Air Mask / Lifeline / Safety Belt / Airline
/ Earmuff etc.
3. Additional precautions if any:.
Issuer Name & Designation Issuer Signature Receiver Name and Designation Receiver Signature
Clearance renewal
Time Gas Test Values Additional precautions Issuer's Name, Receiver Name,
Date for HC's, Toxic, if any, Otherwise Designation & Designation and
From To O2 etc mention “NIL” Signature Signature
Closing of the work permit:
Receiver: Certified that the subject work has been Issuer: Verified that the job has been completed and area
completed / stopped and area cleaned. cleaned and is safe from any hazard.
Date & Time Name & Signature Date & Time Name & Signature
Designation Designation
