Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
BURNING / WELDING / HOT WORK PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of work performing contractor: ________________________ Name of Cont. Site In charge: ___________________ Sign: ______________ Date:_________ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: __________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 The following precautions are to be taken. Item Proper Access/ Exit available Proper ventilation and / or lighting provided Proper & Safe scaffolding, platform, ladder provided Welding machine located in a clean and dry area Welding machine grounded at the equipment & proper leakage current protection device (ELCB) provided for welding machine. Emergency STOP buttons are in working condition. Welder / helper knows how to operate emergency STOP switches Welding machine, Input / Output Cables, welding holder and weld return clamp ( Holder ) insulated & in good condition Welder and fitter trained to connect ground / work return clamps (Holder) to the work piece prior to energization of Welding machine. Gas Cylinders stacked vertically and not below the welding/cutting area. Regulator Key is available with cylinders. Pressure gauges/ Flash back arrestor provided & in working condition. Personal Protective Equipment. Minimum applicable - Safety helmet, safety goggles, welding helmet, safety shoes, leather gloves, long sleeve and nose mask provided. In case of pits, water removed from the pit & wood /rubber insulation provided. Safety Sign board are in place Adequate & suitable nos. of fire fighting extinguisher provided. Near by combustible material removed. Housekeeping Done. Fire watch as standby is in place. Other____________ Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: _____________________ Sign: __________ Date: ________ Time: _________ Name of site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
Yes
Not Required
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___ Original at Site Second Copy- TCE Safety Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
(This Permit is valid only for the date it is issued)
EXCAVATION WORK PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of Work Performing contractor: ________________________ Name of Cont. Site In charge: _______________________ Sign: __________ Date: _______ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: _____________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The following precautions are to be taken Item Proper Access/ Exit available. Exits No slip, Trip, Fall Hazards due to compressed air hose, cable, etc. Proper & Safe scaffolding, platform, ladder provided Daily housekeeping of the work area completed Identification & protection of any utility services like electric cables, pipes etc. nearby before start of work. Checked safe condition of hand tools/ Power tools. Plant, Vehicles safe worthiness checked. Excavated material kept away from excavated edge. Or removed from location. Vehicle access provided, Flag man at location. Shoring / sloping/ benching provided to inside of excavated edges Personal Protective Equipment provided. Minimum applicable are safety helmet, safety goggles, safety shoes, Hand gloves, dust mask, Etc. Solid & strong barricade provided around excavation. Safety Sign board are in place Warning Tape / flash light during night provided around excavation. If excavated more then 1.5 Meter depth Confined space entry precaution in place. Other_________ Yes Not Required
Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: __________________________ Sign: __________ Date: ________ Time: ________ Name of site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___
Original at Site
Second Copy- TCE Safety
Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
(This Permit is valid only for the date it is issued)
ELECTRICAL WORK PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of work performing contractor: ________________________ Name of Cont. Site In charge: _________________________ Sign: ________________ Date: _______ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: __________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The following precautions are to be taken Item Proper Access/ Exit provided. No slip, Trip, Fall Hazards due to Cable , etc. Daily housekeeping of the work area completed. Combustible material kept clear from electrical fixtures. All electrical tools, equipment checked and in good condition. Lock out / Tag out system provided. Cods and connections in good condition (no deterioration) No joints to cables. Disconnected electric supply before starting work on Live equipment Generator is in good condition & double earthing provided. Cables properly protected, bundled, and kept as clear as possible at exits Safety Sign board are in place Proper electrical Personal protective equipment like HV Electrical hand gloves, HV shock proof safety shoes provided. Rubber mat provided both side of control panels. Warning signs, Safety signboards Provided. Adequate & sufficient Nos. of Fire Extinguisher is in place Other______ Yes Not Required
Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: _______________________Sign: __________Date: _________ Time: _________ Name of site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___ Original at Site Second Copy- TCE Safety Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
(This Permit is valid only for the date it is issued)
SCAFFOLD ERECTION/ DISMANTLING WORK PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of work performing contractor: ________________________ Name of Cont. Site In charge: _________________________ Sign: ________________ Date: _______ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: __________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The following precautions are to be taken Item Scaffolder & supervisor trained to erect/Dismantle scaffold. Safety Harness/belt checked and in working condition Safety shoes (nonslip), Helmet with chin strip available with scaffolder. All lifting / tightening tools, equipment checked and in good condition. Check soil condition, If soft soils- use wooden timber as a base plate. All Scaffold tubes, coupler, scaffold boards inspected prior to use. Scaffold tubes- No bent, rust. Couplers- weakened by rust, damaged. Scaffolder instructed to wear/attach safety belt all time and not to work under direct rain, during lightening, heavy wind. Surrounding area 1 meter away from erection site barricaded and warning sign displayed at all location. All wooden ladders are in working order and no step rungs are missing. Protective plastic caps or clothing provided to extended parts of erected scaffolds. No wear & tear of scaffold bags used to handle the scaffold material. After completion of scaffold Do Not Use boards provided. Minimum 3 ladders provided at distance of every 40 meter to use in case of emergency. After completion of scaffold area to be cleaned and unwanted material from scaffold and storage area removed. Other______ Yes Not Required
Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: _______________________Sign: __________Date: _________ Time: _________ Name of site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Original at Site Second Copy- TCE Safety Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___ (This Permit is valid only for the date it is issued)
BLASTING WORK PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Permission of Govt. / local bodies, Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of work performing blaster: ________________________ Name of Cont. Site In charge: _________________________ Sign: ________________ Date: _______ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: __________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. The following precautions are to be taken Item Yes Not Required Whether Permission has taken from all Govt. concerns/local bodies. Pre-blast survey of present utilities completed & precaution taken to avoid any damage to them. Whether pre blast meeting held with local communities for awareness. Are all equipment used for blasting work in good condition and no wear and tear to cables, circuit. No storage of explosives more than required for day blasting available and safely stored at site away form blasting area? Whether competent and approved blaster familiar of hazards of work and safety precaution required appointed for blasting work? Whether all blasting operations shall be covered in such manner as to prevent fragments of rock, gravel, earth, trees, utilities or other substances or materials from being thrown to village area, road, nearby companies? Whether the blasting detection equipment is in working condition? Whether near by companies informed about the blasting work. Submit Off site Emergency Plan. Emergency services like ambulance are available at blast site? Access control to the blasting area to prevent the presents of livestock or unauthorized persons at least ten minutes before each blast ? Safety Siren and warning boards / barricades are placed prior to blast. Precaution taken for any Misfire during blast. Personal Protective Equipment like Safety shoes, helmet, goggles, hand gloves, reflective jacket worned by employees. Other______ Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: _______________________Sign: __________Date: _________ Time: _________ Name of Site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Original at Site
Second Copy- TCE Safety
Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___ (This Permit is valid only for the date it is issued)
WORKING AT HEIGHT PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of work performing contractor: ________________________ Name of Cont. Site In charge: _________________________ Sign: ________________ Date: _______ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: __________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The following precautions are to be taken Item Scaffolding with valid tag available for use Safety Harness/belt checked and in working condition Safety shoes (nonslip), Helmet with chin strip available with employees. All lifting / tightening tools, hand tools /equipment checked and in good condition. Access and exist marked and without obstruction. Lighting arrangement adequate. Unwanted and rubbish material removed from working platform. Electrical cable/ welding hose / compressed air hose properly secured and lay down without obstruction. Signboards provided on working platforms. Employees aware about hazards and safe working practices while working at height. Protective plastic caps or clothing provided to extended parts of scaffolds. Other______ Yes Not Required
Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: _______________________Sign: __________Date: _________ Time: _________ Name of site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Original at Site Second Copy- TCE Safety Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___ (This Permit is valid only for the date it is issued)
LIFTING ACTIVITY PERMIT
Area: __________________________________________ Date: ___/___/____ Time_________ (Area description must be precise Attach Drawing & Risk Assessment.) Name of Site Engineer (Permit Requesting Authority) ___________________________Sign:___________ Name of work performing contractor: ________________________ Name of Cont. Site In charge: _________________________ Sign: ________________ Date: _______ Description of work: ______________________________________________________________ _______________________________________________________________________________ Work Execution Date: __________ Time Valid From: ____________To: ________________ The above signing person will be responsible to ensure that the above described work will be done under all the safety precaution mentioned on the PTW and required by the Project. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The following precautions are to be taken Item Crane used for lifting activity tested, certified and approved for rated lifting works. All lifting tackles, gears/ appliances are tested and certified for lifting works. Crane operator is trained and competent for lifting operation. Lifting belt protected against sharp edge of jobs to be lifted. Access and exist marked and without obstruction. Lighting arrangement adequate. Unwanted and rubbish material removed from working platform. Minimum 2 guidelines has provided for balancing & guiding jobs to be lifted. Periphery area of crane booms as well lifting job is barricaded and Unauthorised/ No entry sign board posted. Rigger and signal man is trained and competent for lifting work. No lifting activity to be carried during lightening, heavy wind /rain. If scaffolding to be used during lift , Scaffolding with valid tag available for use Double lanyards Safety Harness/belt checked and in working condition Safety shoes (nonslip), Helmet with chin strip available with employees. Other Yes Not Required
Name of Contractor/ TCE Safety Officer: _________________ Sign: __________ Date: _____Time ______ Reviewed & Approved By TCE Site Engineer (Permit Issuing Authority): Name: _______________________Sign: __________Date: _________ Time: _________ Name of site Works Co-ordinator: ________________ Sign: ____________
I understand the precaution to be taken as described above and as per Project requirement & here by confirm that Work will be executed under my supervision by following all precaution & Safety Rules.
Name of Work Performing Authority: _________________Sign: __________ Date: ____Time_____ Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn and the site restored to a safe tidy condition.
Name of Work Performing Authority: ________________________Sign: __________ Date: ____Time_____ Original at Site Second Copy- TCE Safety Third Copy- Cont. Site Engineer
Emergency Contact No. Contractor Name: TITLE : SAFETY WORK CLEARANCE Permit No. WO No.
1) 2) 3) 4) 5)
Name of Site Engineer (Permit Requesting Authority) ________________Sign:_____ Date: ____ Time: ___ Name of TCE Site Engineer (Permit Issuing Authority) ________________Sign:_____ Date: ____ Time: ___ (This Permit is valid only for the date it is issued)
Original at Site
Second Copy- TCE Safety
Third Copy- Cont. Site Engineer
