Working at Height Permit
Document No. : PTW/HSE/03
Date : _____/_____/_________ Document Rev.
Permit No. :
This permit must be signed by authorised persons only before work proceeds.
Permit valid for Time ………………………to……………………..
Detailed Location :_______________________________________________________________________
Permit Issued To : - M/s.__________________________________________________________
Contact No.__________________________________
Nature of Work :-_______________________________________________________________________
Following personnels working at Height :
Sr.No Name ID.No. Sr.No Name ID No
1 6
2 7
3 8
4 9
5 10
Checklist to be filled by Permit Issuer / Reciever : - (Tick Appropriate boxes)
Sr.No Check Points Yes No N/A Comments
1 TBT to workmen regarding hazards and working
procedures conducted (Attach Attendance)
Notification to other likely affected contractor /
2
personnel
3 Vertical and catch net below progress floor.
Is there proper access & egress available to the
4 area to be worked upon ?
Is there proper barricading done & supervision
5 provided for guiding & monitoring the work ?
Are appropriate warning signs in place ?
6
Is proper provision of climbing & scaffolding
7 supports & platforms provided for height work?
Are lifelines, fall arrester , safety net ( if
8 applicable) provided ?
Are persons working on height , trained for the
9 same ?
Are task based PPE such as full body harness ,
10 safety handgloves, Fall arrestor etc. being
provided ?
Is precheck for weather condition & wind
11 pressure done before the activity ?
Are tool bag provided for hand tools used at
12 height ?
Is ladder/scaffold inspected & tagged safe for
13
usage ?
Is Overhead electrical cable available near
14
activity location ?
15 Any other precautions taken:
Permit Reciever :- (We have checked the requirements and it's safe to proceed with work. All workers are physically and me
Name :- ____________________________________________ Sign___________ Date________________
Signing Authority
Project Engineer Work Supervisor Safety Personnel
Date Date Date
Time Time Time
Name & Sign Name & Sign Name & Sign
Permit Cancellation
Reason of Cancellation:
Name: __________________________.Signed: _____________ Time: __________________
Permit Extension Signature
Permit Extended for Time ____________________ to ________________
Project Engineer Work Supervisor Safety Personnel
Date Date Date
Time Time Time
Name & Sign Name & Sign Name & Sign
Permit Closure Signture
Project Engineer Work Supervisor Safety Personnel
Date Date Date
Time Time Time
Name & Sign Name & Sign Name & Sign
Patroling by Safety Officer / Security Officer / Security Guard
Shift Name Patroling time Signature
**सुरक्षा सूचना **
१) साईट सुपरवायझर कामाच्या ठिकाणी हजार असावा.
२) काम झाल्यावर सर्व क्षेत्र स्व्च्छ ठेवा .
३) योग्य त्या सुरक्षा साधनाचा वापर करावा .
४) काम चालू असणाऱ्या ठिकाणी सुरक्षा सुचनाचे किवा धोक्याचे फलक लावावेत
५) काम चालू असणाऱ्या ठिकाणी येण्या जाण्यासाठी मोकळा मार्ग असावा
६) तात्पुरते वापरात येणाऱ्या शिड्या ,पायऱ्या व उतरंड हे चांगल्या परीस्थित आहेत ह्याची
७) अति वाहतूक ग्रस्त भागांमध्ये काम करताना काळजी पूर्वक काम करावे .
८) काम करते वेळी चांगली उपकरणे वापरावीत,झिजलेली उपकरणे वापरू नयेत.
९) कोणत्याही चालू इलेक्ट्रिक पॅनलवर काम करतेवेळी विद्युत सप्लाय पूर्णपणे बंद ठेवावा.
करून नंतर काम करण्यास सुरुवात करावी.
१०) प्रत्येक इलेक्ट्रिकल उपकरणाला चांगला प्लग असावा.
workers are physically and mentally fit.
Date________________ Time___________
ty
Safety Personnel Client Representative
Date Date
ime Time
Name & Sign Name & Sign
tion
____
nature
Safety Personnel Client Representative
Date Date
ime Time
Name & Sign Name & Sign
nture
Safety Personnel Client Representative
Date Date
ime Time
Name & Sign Name & Sign
Officer / Security Guard
Remark
चना **
लावावेत
परीस्थित आहेत ह्याची खात्री करा .
वे .
त.
पूर्णपणे बंद ठेवावा. तसेच लोटो सिस्टिम ची अंमलबजावणी
