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Person(s) Before Work Is To Proceed and Only Work Listed Above May Be Completed

This permit document authorizes work at heights at a specified site and location. It lists the contractor, date, time period for which the permit is valid, and describes the works. An attached JSA, SWMS or SWP must be provided. Equipment to be used, isolated services, control measures implemented, and environmental factors assessed are documented. The permit must be prominently displayed and authorized by the permit issuer and contractor before work proceeds. Upon work completion, the permit can be cancelled and the worksite inspected and declared safe to resume normal operations.

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Ramasubramanian Sankaranarayanan
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37 views2 pages

Person(s) Before Work Is To Proceed and Only Work Listed Above May Be Completed

This permit document authorizes work at heights at a specified site and location. It lists the contractor, date, time period for which the permit is valid, and describes the works. An attached JSA, SWMS or SWP must be provided. Equipment to be used, isolated services, control measures implemented, and environmental factors assessed are documented. The permit must be prominently displayed and authorized by the permit issuer and contractor before work proceeds. Upon work completion, the permit can be cancelled and the worksite inspected and declared safe to resume normal operations.

Uploaded by

Ramasubramanian Sankaranarayanan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Permit to Work Work at Heights Permit

Permit Number:

Site:

Location:

Contractor/
Employee:

Date:

Phone:

This permit is valid from:

am/pm

On:

This permit is valid until:

am/pm

On:

Description of works:

A Safe Work Method Statement (SWMS), Job Safety Analysis (JSA) and/or Safe Work Procedure (SWP)
has been provided and is attached to this work permit Yes
No
Note: The following section of this permit must be completed and signed by the authorised
person(s) before work is to proceed and only work listed above may be completed.
The following equipment will be used during the works
use):

(all equipment to be used is in good working order and is fit for

scissor lift)

Roof and/or ladder anchor


points

Ropes and harness

Step ladder

Extension ladder

Edge protection

Mobile scaffold

Appropriate footwear

Safety net

Elevated work platform

(i.e.

Other (please specify):

The following services have been isolated for the duration of the works:
Smoke / thermal detectors

Pipes, tanks and valves

Electrical Outlets / appliances

Other (please specify):

The following control measures have been implemented for the duration of the works:
Barricades

Signage

Spotter

Other (please specify):

The following environmental factors have been assessed and are suitable for the works:
Weather / wind

Stored material / vegetation

Other (please specify):

This permit should be prominently displayed at the work site


Authorisation
Permit Issued To:
(Print name)

(Signature)

(Date)

Permit to Work Work at Heights Permit


Permit Issued By:
(Print name)

(Signature)

(Date)

Cancellation/completion of permit
Permit cancelled/returned by:
(Print name)

Cancelled/returned at:

(Signature)

am/pm

On:

Reason for cancellation :

Final Sign Off


The worksite has been inspected by me at the cancellation/completion of the work at heights and declared safe for
normal operations to resume.

(Print name)

(Signature)

(Date)

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