HOT WORK PERMIT

DATE:

PERMIT TO WORK NO:

PROJECT:

LOCATION:

CONTRACTOR:

CONSULTANT:

EMPLOYER
NATURE OF HOT
WORK:

IGNITION SOURCE:

electrical equip ment

tools

open fla me

v e hicle

e xtension leads

other

PARTICULAR HAZARDS & CONTROL MEASURES:

SPECIFIC PPE:

hearin g protection

safet y harness

dust m ask

hot w ork clothin g

rubber boots

g o g gles

other

face shield

glo ves _______

SPECIFIC
EQUIPMENT:

Fire blanket

Safet y barriers/signs

Fire E xtin guisher

Fire hose

Portable gas
detector

(t y pe)

che mical suit

other

GAS TEST RECORD:

Frequenc y of tests:

Continuous m o nitorin g : Yes/No

Date/Time
Tester
O2 %

(19.5 %

22.5)

LEL %

(% 10)

O ther
REVIEW AND AUTHORIZATION:
I, the appro vin g authorit y, ha ve inspected the w o rk area and hereb y con firm it is safe to perfor m this
task under the conditions of this per mit.
Na me:.. Signature.. Date..
...
I, the per mit coordinator, ha ve re vie w ed this per mit and supportin g doc.s and con firm that the y are in
co m pliance w ith the per mit procedure.
Na me:.. Signature.. Date..
...
I, the perfor min g authorit y, accept the conditions stipulated in this per mit and con firm that all control
m easures and isolations are in place.
Na me:.. Signature.. Date..
...

CLOSE OUT:
THE W O RK IS COMPLETE
THE W O RK IS INCOMPLETE A N D LEFT IN THE F OLLO WING CON DITION (STATE REASON):
Perfor min g authority: I declare that the w ork for w hich this per mit w as issued has been properl y
perfor med, and that the area has been left in a safe, clean, condition.
Na me:.. Signature.. Date..
...
A ppro vin g authority: I ha ve inspected the w ork area and declare that the w ork for w hich this per mit w as
issued has been properl y perfor med, and that the area has been left in a safe, clean,
Na me:.. Signature.. Date..
...
PT W coordinator: I declare that this per mit to w ork has been closed out as per per mit to w ork procedure
and been log ged into the per mit to w ork register under the docu ment control g roup (DCG )
Na me:.. Signature.. Date..
...
Hot Work Permit