Ref No.: GPL F HS 24 Rev.No.

00
Date 20-10-2020 PTW NO:-…………….….

Permit To Work - HEIGHT WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance of the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of
Date / Time / Sign
extension required authorization as above is " MUST".
HEIGHT WORK - Check Points
Any work on, below, or above ground level where there is risk of personal injury through falling and/or a potential risk to people below the work site being injured by falling
objects.s.

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted (Attach
1 YES NO N/A
Attendance)
2 Notification to other likely affected contractor / personnel. YES NO N/A

3 Height pass issued to all the workers working at height. YES NO N/A

4 Personnel provided with full body harness, fall arrestor & life line. YES NO N/A

5 ladder and scaffold secured and supported propely. YES NO N/A

6 Weather condition normal and high wind pressure observed during the height work YES NO N/A
Working platform with full decking, double railing, access ladder, bracing, toe board,
7 YES NO N/A
base plate/wheel lock etc…. Provided.
8 Working area bellow safely barricaded. YES NO N/A

9 Are around the workplace cleared and all scraps removed after complition of work. YES NO N/A

10 All tools are fit and properly anchored and carried in bags / tool kit. YES NO N/A

11 Vertical and catch net provided below progress floor. YES NO N/A

12 Supervision available at the place at all time. YES NO N/A

13 Whether illumination of mim 50LUX maintained at the work location. YES NO N/A

14 YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline Equipments / Hand tools Fittness Fire Extinguisher Supervision
v
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing Emergency Vehicle Weather Condition Medical Fitness

v v
v Other (Please Specify):
Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as
property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : ____________________________________________
Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action
Contractor EHS Engineer / Manager : - ______________________________________
Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Completion Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by work Work Completion Handover:
release authority. PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.