Format No.

- FRM/EHS/04 Hot Work Permit

Revision No.- Rev. 02
Date and Time Issued: Date and Time Expires:
Job / Site / Space I.D. : Job Supevisor :
Equipment to beworked on :
No.of Persons involved :
Name of the Perosns involved :
1. 2.
3. 4.
Work to be performed:

HOT WORK CHECKLIST : N/A Yes No.

1. Job Site Checked : ( ) ( ) ( )
2. Combustibles removed ( ) ( ) ( )
3. Area cordoned off : ( ) ( ) ( )
4. Sparks isolated: ( ) ( ) ( )
5. Explosion test done : ( ) ( ) ( )
6. Welding Set earthed ( ) ( ) ( )
7. Electric Cable & Rubber Pipe Checked ( ) ( ) ( )
8. Adequate ventilation for fumes ( ) ( ) ( )
9. Fire Extinguishers provided with valid date ( ) ( ) ( )
10. Fire Extinguishers type and No.
11. Fire watch in place ( ) ( ) ( )
12. Fire Watch Name
13. Precaution to be taken, if any

PPE TO BE USED : [Tick which ever is applicable]

1. Helmet : [ ] 5. Welding goggles : [ ]
2. Safety Shoes : [ ] 6. Gloves : [ ]
3. Gum boots : [ ] 7. Respirators / Mask [ ]
4. Welding face shield [ ] 8. Apron [ ]
9. Safety glasses/ Goggles [ ]
Permit Prepared By :
Name : Signature :
Reviewed By :
Name : Signature :
Approved By :
Name : Signature :
Permit Acceptance (in case of contract job) :
I have been explained the contents of this permit and have been provided necessary PPE. I shall be responsible for
supervising the job. I assure you to follow all safety precautins.
Name of the Contractor : Name :
Signature :
This permit to be kept at Job site. Return job site cipy to Engieering Department following job completion.
PERMIT CLOSING DETAILS :
Name of the employee :
Signature :
Date & Time :
Copies : White -Original (Job Site) Yellow (Engg. Deptt.)
Format No.- FRM/EHS/05
Revision No.- Rev. 01
Lock Out and Tag Out Permit
Date and Time Issued : Date and Time Expires :
Job/Site / Space I.D. : Job Supervisor:
Equipment to be worked on :
Work to be performed:

1. Equipment / pipeline / pump locked out by :

Name: Signature :
Verified by:
Name: Signature :

2. Source isolation : N/A Yes No.

Pipelines blinded [ ] [ ] [ ]
Pipeline isolated [ ] [ ] [ ]
Pumps locked [ ] [ ] [ ]
Pumps isolated [ ] [ ] [ ]
Valve licked [ ] [ ] [ ]
Do not operate Tag displayed [ ] [ ] [ ]

3. Electrical energy isolation : N/A Yes No.

Fuse removed [ ] [ ] [ ]
Panel / switch locked out [ ] [ ] [ ]
Do not operate tag displayed [ ] [ ] [ ]

We have reviewed the work authorized by this permit and the information contained here-in. Written instructions and
safety procedures have been received and are understood. Entry cannot be approved if any squares are marked in the
“No” column. This permit is not valid unless all appropriate items are completed.

Permit Prepared By :
Name : Signature :

Reviewed By:
Name : Signature :

Approved By:
Name : Signature :

This permit to be kept at job site. Return job site copy to Engineering Deptt. Followig job completion.
PERMIT CLOSING DETAILS :
Name of the employee :
Signature :
Date & Time :

Copies : White - Original (Job Site) Yellow (Engg. Deptt.)

 Format No.- FRM/EHS/06
Revision No.- Rev. 01 Master / General Work Permit
Date and Time Issued: Date and Time Expires:
Job/Site/Space I.D .: Job Supervisor

: Equipment to be worked on:

Work to be performed :

No. of Personeel :
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
Precuations to be taken, if any

PPE TO BE USED : [Tick whichever is applicable]

1. Helmet : : [ ] 5. Welding goggle : [ ]
2. Safety Shoes : [ ] 6. Gloves : [ ]
3. Gum boots : [ ] 7. Respirators / Mask : [ ]
4. Welding face shield : [ ] 8. Aprin : [ ]

Permit supporting this Master / General permit

a) Hot work permit - R / NR
b) Height work permit - R / NR
c) CSE Permit - R / NR
d) LOTO Permit - R / NR

Permit Prepared by :
Name : Signature :
Reviewed By :
Name : Signature :

Approved By :
Name: Signature :
Permit Acceptance [in case of contract job]:
I have been explained the contents of this permit and have been provided necessary PPE. I shall be responsible for
supervising the job. l assure you to follow all safety precautions.

Name of the contractor : Permit Closing Detail

Signature :
This Permit to be Kept at job site. Return job site. Return job site copy to Engg. Deptt. following job completion.

This Permit is valid only for Cleaning and Genral Maintenance activities and preparation for further permit requirements.
Copies: White- Original (job Site) Yellow (Engg. Deptt.)
Format No.- FRM/EHS/03
Revision No.- Rev 02 Height /Fragile Roof Work Permit
Date and Time Issued: Date and Time Expires:
Job Site / Space I.D.: Job Supervisor:
Equipment to be worked on:
Name of the Persons involved:
1. 2.
3. 4.
Work to be performed:

Height/Fragile Roof work Checklist:

1. Scaffolding properly constructed: ( ) ( ) ( )
2. Footing of scaffold rigid and sound: ( ) ( ) ( )
3 Footing supported on rigid surface: ( ) ( ) ( )
4. Planks are over-lapped and tied properly: ( ) ( ) ( )
5. Scaffold securely and to permanent structure: ( ) ( ) ( )
6. Scaffold securely and rigidly braced to prevent swaying and displacement ( ) ( ) ( )
7. Scaffold equipped with guardrail, midrails and toe-board: ( ) ( ) ( )
8. Barrels, boxes, bricks and concrete block are not used tosupport scaffold/plank: ( ) ( ) ( )
9. Scaffold 10 feet away from electric lines: ( ) ( ) ( )
10. Rigid fixture available to hook safety belt: ( ) ( ) ( )
11. Provisions available tosecurely support crawling board / duck ladder ( ) ( ) ( )
12 .Safety belt is in good condition: ( ) ( ) ( )
14. Other precautions if any
PPE TO BE USED : [Tick whichever is applicable] Copies : White - Original (Job Site) yellow (Engg. Deptt.):
1. Helmet with chin strap : [ ] 2. Safety Shoes [ ]
3. Gum boots [ ] 4. Welding face shield [ ]
5 Respirator [ ] 6. Gloves: [ ]
7. Safety Belt / Full body harness [ ] 8. Any Other PPE
We have reviewed the work authorized by this permit and the information contained here-in.Written instructions and safety
Procedures have been received and are understood.Entry cannot be approved if any squares are marked in the “No” column.This
Permit is not valid unless all appropriate items are completed.
Permit Prepared By :
Name : Signature :
Reviewed By :
Name : Signature :
Approved By :
Name : Signature :
Permit Acceptance (in case of contract job :
I have been explained the contents of this permit and have been provided necessary PPE. I shall be responsible for
supervising the job. I assure you to follow all safety precautions.
Name of the Contractor :
Signature :
This permit to be kept at job site. Return job site copy to Engineering Department following job completion.
PERMIT CLOSING DETAILS :
Name of the employee :
Signature :
Date & Time :
Copies : White - Original (Job Site) Yellow (Engg. Deptt.):