R4G-80-HSE-FMT-PR-026

Reliance Jio Infocomm Limited

WORK PERMIT Work Permit No.
(Work at Height/Hot Work/Excavation/Electrical/Confined Space)
t. v<uom'
Date: 2. ISSUING DEPT: 3. ISSUED TO:
Time Stare:
T‹me end:

JODlOCADON: STATE: MAINTENACE POINT: EACILTTY:

6. HAZRADS IDEA\ITIFIED (JOINTLY BY ISSUER AND ACCEPTOR)

High Winds Q Fumes Q Traffic @ Lone Work
Flammables Q High/Low Pressure @ Confined Burried Cables
flplosves Q High/towTemp Space @ Lack of @ Burried Pipelines
Compressed gas Q Live Electrical Oxygen @ Use of HT/LT Line near workplace
Q Hot Materials Q Overhead Danger Ladder Low / No Parapet Wall
LIfving Machines Q Movlng Machine Use of @ Heavy Rain
Dust Auto-start equipment Scaffold @ @ Others (Specify):
Unsafe Access
Fragile Roof
7. PPE TO BE
USED @ Safety @ Hand Face Shield Q Dust / Mist Mask
Helmet Q Safety Gloves(Electrical) Q Q Reflective Jacket Full Body Harness
Shoes Hand Gloves(Leather) Q Q PVC Overall Q Safety Net
Gum Boots Hand Gloves (Cotton) Q Q Ear Plug / Ear Mull Fall Arrestor
Hand Gloves (PVC) Safety Goggles Q
Crawling Board Q Other(specify)
8. SPECIFIC HAZARDS & CONTROL MEASURES
(No be filled by issuing person in consultation with competent person as required e.g. SME Power & Utllity for utility maintenance jobs. (attach separate
mechod statemen, t if required):

9. ISOLATIONS REQUIRED: 0 YES NO TAG NO.:

Eleccrical Isolation Including Motor Isolation: Yes /
No
Drive / Electrical Panel / Battery Bank / Smps Involved:
How Isolated: Q Tested Non-Operative
Q Fuse Removed Q Disconnected Batteries
Q Isolator put off & Locked
10. PRECAUTIONS CHECKLIST

(A) GENERAL {for all jobs) (B) ELECTRICAL WORK (C ) CONFINED SPACE WORK ( D ) EXCAVATION
Q Job Site Checked Electrical Isolation Q O2 Monitoring done Q Underground Cables Checked
Area Cordoned done Lock Out Tag LEL monltorlng Underground Pipes Checked
Caution Board Displayed Out done Done Shoring Arran8ement Done
E LCB for Portable Tools Competent Person doing job Adeuqate Ventilation Provided DIAL Before Dig Ref no.
PPE Provided Other Rescuer/ Buddy Avallable n Entry & Exit Pit Barricaded
Q Lift ing Tools Certified Communication Arrangement @ Portable Light for Night ¥Vork
Load Test Certificate done n HDD M/c Bar roe aded
SupervJslon Provided @ 24 V Lamp Provided D \sh‹ ng Tools Insulated
Q F rst Ald Kit Ava ilable D/G utilit res exposed/ protectsd
(E) WORKING AT
De water ing Ar r ang+men t
HETGHT/ROOF (F) HOT WORK
Oon e Loo kout M an Ava luble
Q Ba rrlcading of Work Area Q Combustibles ftemoved
Marking P it \vI th LIme
Q Ladde r Checked 0 Sparks Isolated
Q Scaffold Checked Q Fire E xtlnguisher Provided Poxvcle r D ictlng E nd PIug Ar
Q Safety Nei Installed ranged
{d Fire FIghters Alerted
Q Barricading Below Cross P I for Utility N'la
0 Welding Sets Earthed
Q Access Route Cleared 0 Weld cables in good condition rking Intlma tion to Traffic
Q Arrange to Tie Harness 0 Adequate V entllatlon provided Police IFC Dra wing
Q Resc uer/Buddy Provided rire Dlanket provlded Available
Q Use of Fall Arrestor 0 Other SUV Or<Jwlng for HDD S

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 R4G-80-HSE-FMT-PR-026

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11. PERMIT ISSUER : Contractor/Employee/Supervisor has understood the hazards and agreed to comply with the requirements.

Name of Issuer: Signature: Time / Date:

12. PERMIT ACCEPTANCE: I have been explained the content of this Permit w.r.t. hazards involved in the job, precautions to be taken
and have been provided necessary PPEs. I shall be responsible for supervising the job and ensuring compliance to the
rquirements.Persons whose name are recorded shall working under me.

Name of Acceptor: Signature: Time / Date:

13. WORK COMPLETED:The job described in thls permit has been completed. All safety devlces put back, area cleaned &
cleared.Persons on the job withdrawn.
Name of Acceptor: Signature: Time / Date:
Name of Issuer: Signature: Time / Date:

14. WORK SUSPENSION: The job described in this permit has not been completed and has been abondoned. No further work shall be
undertaken under this permit.
I request the permit to be cancelled. If, the work is to be taken up again a fresh permit will be required.

Name of Acceptor. Signature: Time / Date:

Name of Issuer- Signature: Time / Date:

1S.ELECTRICAL ENERGISATION (TO BE AUTHORISED BE’ PERMIT ISSUING PERSON AND DONE BY THE ELECTRICIAN)

Name of Issuer: Signature: Time / Date:

Electrician: Signature: time I Date:
16. PERMIT CLOSED:

Name of Issuer: Signature: Time / Date:

17tNAME OF EMPLOYEES ON THE JOB

2 5

3 6

18. PERMIT HANDOVER / EXTENSION:

Pemit Valid Date & Name of lssure Signature Name of Acceptor Signature
Time

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