HEIGHT WORK PERMIT
Name of Project : Cipla Pharmaceutical Ltd. Kurkumbh
Date: _______________ Time: From ___________ Hrs. To ________Hrs. SWMS/ JSA No.: ________________
Contractor Name: _______________________________________________ S. No: ____________________
Max. No. of workers (All Skill Trades): __________ Area / Site Location: __________________________________
Tools and Equipment Involved:
Work description (in Brief):
Working at Height Permit
Safety Precautions: -
S. No Description Yes No S.No Description Yes No
1 Please mention the approximate height 11
of the floor---------------meter(s) Climatic Conditions are suitable: _________
2 Work Platform inspected 12 Ensure that scaffolding is mechanically strong and
authorized tag provided
3 Adequate notices are posted in the 13 Fragile roofs, and ducts identified and marked with
vicinity adequate barricades
4 Area Occupants are protected from 14 Second person required
falling debris/materials
5 Safety full body harness/Safety 15 Suitable lighting arrangements are available during
Equipment / Personal Fall arrestor night hours
inspected
6 Safe and sufficient means of access and 16 For Work Scheduled during night hours relevant
egress have been provided. permission obtained from authorities
7 Trained and height work pass person 17 Ensure that the anchoring points are available to fix
deployed for work the lifeline
8 Direct communications are possible 18 Coordination /Communication with concerned
always Parties (If any).
9 Underneath are barricades and placed 19 Have the person carrying out the activity been
notice provided with proper Personal Hand
Protective Equipments – (Helmet / Reflective
Jackets /Safety Shoes / Safety Goggle / Face Shield/
Gloves / Mask / Earmuff)
10 Ensure that scaffolding is mechanically 20 Use safety ladder.
strong and authorized tag provided (Ladder to be extended by one meter beyond the
place of work).
21 If scaffold is used fill the scaffold checklist and signature of civil engineer.
I/We accept the work and understand the Safety Instructions regarding the use of Safety Equipment given to me/us. I/We
shall abide and implement these while working.
22. All the above precautions have been put in place:
23. Any additional precautions required (If no one state)
24. Permit Initiation: I understood the hazards associated with the work and instructions elaborated to accomplish the task. I shall
follow precautions mentioned in the PTW and all the safety rules of the organization.
Permit User department Verified by Safety officer: (Vendor) Issuing Authority: (JLL*) Safety Officer: (JLL*)
initiated by: (Vendor) Name: Name: Name:
Name:
Signature: Signature: Signature:
Signature:
25 *Note: In case of absence of JLL team, CPL authorized team shall be approved by the permit.
26. CPL authorization person Name: _________________________Signature: ___________________Date & Time: __________
27. Any Comments:
28. Permit extension date on: ______________________ from time: _____________hrs. to time: _______________ hrs.
HEIGHT WORK PERMIT
Permit User department Verified by Safety officer: Issuing Authority: (JLL*) Safety Officer: (JLL*)
initiated by: (Vendor) (Vendor) Name: Name:
Name: Name:
Signature: Signature:
Signature: Signature:
SCAFFOLD PERMIT
28. CERTIFICATION OF SCAFFOLD FOR USAGE BY CIVIL ENGINEER –
S. No Check Points Yes No NA
a. Tubular Pipe: Quality (Including free of defects and corrosion) - Diameter (not less than 40 mm at any section) -
b. MS Mesh: Quality - Thickness (at least 8-10 mm) - Width (at least 400 mm) - Spacing between bars (NMT 30 mm) -
c. Quality and suitability / compatibility of clamps (Coupler) with pipe -
d. Vertical Pipes (1800 mm to 2400 mm distance between two adjacent Tubular Pipes) -
e. Horizontal Pipes (Not more than 1200 mm distance between two adjacent pipes) -
f. Diagonal Pipes (Where height of scaffold is more than 3000 mm) -
g. Ensure that, flooring can take scaffold load. Flooring for base support (Hard & non slippery, provide base plates below the tubular
pipes) -
h. Putlog connected to wall / other support should be firm & secure. -
i. Joints of 2 sections of vertical pipes (Overlap of at least 600 mm) -
j. Planks are fastened at both ends by rope / metal wire with overhang of not less than 200 mm and more than 300 mm at each end -
Note:
1.
This Height work permit is valid for one day only.
2. k. The support
No work permit
has times
beenare fromfrom
taken 08:00pipes
to 17:00 hrs. Extension
or other temporary permit
times are
supports. - 17:00 to 20:00 hrs.
(**If the work shall not be completed within the stipulated time, then extension up to 22:00 hrs. with prior approval from the CPL project manager and KKB EHS head.)
l.
** Based on Toe railing
the work (about
plan, 100extension
the work mm height from
is after 22:00
plank) -
hrs. Plant Hand railing
manager (about
approval 900 mmBut
is mandatory. height
from plank)
the respective -
department's Top
complete team (Vendor, JLL, or CPL) must be
3.
present at site.)
railing (about 1500 – 1800 mm height from plank) - Top railing to be use for hooking-up of lifeline of safety belt -
It is the responsibility of the initiating department to follow the scaffolding permit where scaffolding work is performed. (S. No: 28)
4. m. The blockage
No vendor userofdepartment supervisor
Fire Fighting or Engineer
Equipment, shallEquipment,
Safety initiate the work permit switch
Electrical system as per s.no
board, 24.
Emergency
Doors etc. -
5. It is the responsibility of the vendor safety officer to ensure all safety arrangements are made as per the check list.
n. Ensure that, open ends of the horizontal pipes are covered / closed properly. (Minimum 6 ft from floor level)
6. The JLL team is responsible for granting permit authority and issuing the permit. (Before authority to ensure all safety precautions as per the check points)
7.
o. Scaffolding on recommendations
If any additional the top of the passage has been
or comments shallprovided
go throughwith horizontal screen to catch falling object - Done
S.No.27. NA.
In the absence of the JLL team, the CPL authorized team shall be approved by the permit.
8.
9.
(Only in case where man-material movement is restricted)
The CPL authorization person shall check and sign off on the work permit according to S.No.26.
10. p. Unspecified
As per S.No.28, Hazard & Other
the extended Measures
permit shall be to be taken:
initiated at 16:30 hrs. It is following the sign-off process.
11. During extended permit CPL responsible persons shall be on site till closing of the permit.
12. After completion of the work shall be close the work permits as per S.No.29,30, 31 & 32.
13.29. Closing It isof
thethe PermitofTime
responsibility __________&
the permit Date _____________
user (Vendor Supervisor/Engineer) to follow the at which
safety the permit
precautions mentionedisinclosed.
this permit.
14. Before starting the job, the Permit Issuer should review the impact of the activity on any other activities in the vicinity and vice versa.
15.30. NameThe of Supervisor
the Issuing shouldAuthority:
ensure that the_____________________________Signature:
person carrying out the job fully understands the job and necessary______________Date & Time: ___________
precautions to be taken during work.
16. This original copy of the permit should be displayed at site while carrying out the job, duplicate copy should be stippled with permit book and original copy should be
31. Name
returned to theof thedepartment
safety Safety officer: _______________________________
after completion of job. Signature: _______________Date & Time: ___________
17. This permit is valid for the prescribed period only with the concurrence of the respective officers.
18.32. NameIn ofcasetheof CPL/JLL responsible
emergency/Safety deviation, theperson: ____________________
permit should be cancelled forthwith & reissued Signature: ______________Date
after the emergency & Time:
is over & the area is declared safe. ___________
HEIGHT WORK PERMIT
Scaffold No. ____________
Scaffold Erected by: ________________________________
Scaffold is under
erectioning/
Scaffold is safe Incomplete.
and ready for use. Not ready to use.
Inspected and Certified by:
Name:_________________________________
Sign_________________ Date______________
