Format No.
: MPIPL/HSE/F-002
PERMIT TO WORK
Rev. No. : 00 / Date : 01.08.2024
Permit No:
Permit Valid: 08 Hrs. Only
This Wok Permit should be available with the persons doing the work. On demand, he should produce the permit. Job should be done only
by permitted persons and only at permitted location. In case of abnormal condition, inform the supervisor. Permit is valid for one day only
on the mentioned date & time.
Site/Location Permit issue date & time
Company /
Permit valid up to time
Contractor Name
Type of work
Job Description
Required PPE for work to be carried out: (Please tick below the sentences
Safety Helmet, Safety Shoe, Gum Boot, Safety Harness, Nose Mask, Hand Gloves, Face Shield, Goggles, Safety Nets, Life Line, Apron, Ear Plug, Cover
all, Reflective Jacket, Any Specific:
Note : Additional work specific PPE, as decided by the team General Precautions for all types of work:
Contractor’s Supervisor available to inspect & control work at Adequate Lighting provision made in case work needs to
1 4
site. carry out after sunset also (with PTW renewal)
2 First Aid box available at work site 5 LOTO applied (wherever applicable)
3 Required Firefighting equipment’s are available at work site 6 Warning / cautionary sign boards are displayed
4 Sufficient Illumination available at work site 7 Any other requirements:
Precautions to be taken before starting the work
ERECTION / De-ERECTION / HEAVY IEQUIPMENT
EXCAVATION / CIVIL WORK WORKING AT HEIGHT
HANDLING
Area cleared from Electrical Cables
Crane & lifting tools tackles are inspected
/Blasting etc. & All unwanted material Proper access is provided
and certified by competent authority.
removed from work location.
Excavator & other equipment’s Operators are trained & license holder for
fitness verified. operating crane. Barricaded area before starting the work
Capacity of crane and others tools tackles are Work platforms provided are with guard
Barricaded area before starting the
checked and verified against total load to be rail & are of sufficient space.
work
lifted.
Ladder & scaffolding or other means All hand tools are secured against
of access provided. Trained signal man and rigger are available. accidental fall.
Warning boards displayed indicating
falling hazard. Crane platform is properly compacted. Workmen provided with tool bags.
Excavated soil shall be kept minimum
Electrical line clearance from any moving
1 meter away from edge of pit or Loose materials at height are secured.
parts like crane.
1/3rd of total depth of excavation.
All electrical fitments & supply lines Guy rope / tagline provided to control the Authorized supervisor must be at work
are safe to operate. materials movement. location
Crow bars with rubber handles All employees are physically fit to work
Follow all instruction for working at height.
provided. at height.
ELECTRICAL WORK HOT WORK LOADING & UNLOADING
All flammable items/goods isolated, fire Follow all instruction for working at
Electrical Supply isolated & locked.
extinguisher, water bucket provided height
Cylinders kept vertical & hose pipe checked Crane, lifting tools & tackles tested
Adequate earthing provided.
for cracks.
LOTO followed. Flashback arrestors are provided Operator is trained & license holder
All tools are in good condition and Hot work suit /apron with respective PPE
Area cleared from man & material
insulated. provided.
Availability of authorized electrician. Area barricaded /closed. Guide rope used for guiding the material
LOTO Details: Special Precautions to be taken, if any:
We HAVE reviewed all necessary precautions to be taken to protect the personnel engaged in this work from accident and injury.
Permit Issued by (Authorized Person) Work Initiator Permit received by Company / Contractor
Supervisor Name /Date / Time / Sign Name /Date / Time / Sign Name /Date / Time / Sign
Special precautions to be taken if any:
Format No.: MPIPL/HSE/F-002
PERMIT TO WORK
Rev. No. : 00 / Date : 01.08.2024
Permit No:
Permit Valid: 08 Hrs. Only
This Wok Permit should be available with the persons doing the work. On demand, he should produce the permit. Job should be done only
by permitted persons and only at permitted location. In case of abnormal condition, inform the supervisor. Permit is valid for one day only
on the mentioned date & time.
TOOL BOX TALK (TBT): If team members are more than 10 then attach separate sheet
Topic Covered :
A Team members present
Sign
Sl. No. Name Sign Sl. No. Name
1 6
2 7
3 8
4 9
5 10
Procedures/Document: Check Points (Please check the following points and tick mark accordingly)
Sl. No.
Details Discussion done Remarks
1 Procedures related to this activity. Yes No
2 Checklist related to this activity. Yes No
3 HIRA/Aspect Impact available & discussed. Yes No
Discussion on previous incidents performing similar work
Sl. No. Details Discussion done Remarks
1 Unsafe Condition/Unsafe Act Yes No
2 Near miss Yes No
3 Incident/Accident Yes No
4 Property damage Yes No
PPE Availability (Please mention below the list of PPE being used)
Sl. No.
Details PPE is OK Remarks
1
Safety Shoes Yes No
2 Yes No
Safety
Helmet
3 Safety Harness / Fall Arrestor Yes No
4 Yes No
Work Permit Renewal (In special cases only on the same day. Not valid for next day)
From: am/pm to am/pm
Permit Issued by (Authorized Person) Work Initiator Permit received by Company / Contractor
Supervisor Name /Date / Time / Sign Name /Date / Time / Sign Name /Date / Time / Sign
Work Permit Closure
Work satisfactorily completed. .
Work not finished, to be continued with a new work permit issued by competent personWork
suspended, as present conditions are not conductive for carrying the work safely.
Details of any other reason for closure / cancellation
Permit Returned by
Name/Date/Time / Sign
