PERMIT TO WORK

SHAFTS AND ELEVATORS

PERMIT NUMBER
# people in workgroup
Name of co-workers
AREA OF WORK/FLOOR
Shaft location:
DESCRIPTION OF WORK:
COMPLIANCE CHECKLIST CHECK FOR COMPLIANCE

Forman Supervision (or watcher outside the shaft)

Safe Access and Egress on Landings using ladders
Proper illumination
Overhead protection (from falling objects)
Solid safe working platforms with appropriate gap closures
Lifeline Full Body Harness in Good condition & all buckles clipped
Other PPE (Helmet/Gloves)

Note: Issuer discussed the risk of falling materials hazards to the recipient to ensure no possibility of harm will hit
any worker or damage any property on the bottom of the work area. This is done by placing isolations and worker
on the bottom of the workplace. Work will carry on unless the risks are removed. *Noticable defects will
immediately stop the work and report to safety to address the problem.

DURATION OF PERMIT (HOURS):

DATE AND TIME OF ISSUE:
VALID UNTIL:
AREA IN CHARGE (FORMAN):
SUB CONTRACTOR(S) SAFETY OFFICER:
NAME OF SNC SAFETY OFFICER/SAFETY IN CHARGE:
Permission to start: I Name & Signature of Receiver Signature of SNC Safety Officer/Safety in charge:
have personally checked
the area and confirmed
the precautions in place.

PERMIT CLEARANCE (BELOW)

Permit Clearance: Work Signature of SNC Safety Officer/Safety in charge:
is completed, the area is
cleared, Isolations and
hazards are removed.

TIME CLEARED:
DATE CLEARED: