HEIGHT WORK PERMIT

Building / Block: Permit No:

Tower: Wing & Floor:

Work Area Details:

DESCRIPTION OF WORK

DETAILS OF THE COMPANY / CONTRACTOR UNDERTAKING THE WORK

Name of the Company: Name of the Work-in-charge:
(Provide contact details)
No.of Personnel Deployed: (Please provide names of all in a separate list)

DETAILS OF PERSONNEL PROTECTIVE EQUIPMENT (PPE) TO BE USED DURING THE WORK (PLEASE TICK)

Goggles Safety Shoes Hard Hat (Helmet) Protective Gloves

Safety Net Safety Harness Scaffolding Overall

Any Others:
( Pl Specify)
DETAIL ALL HAZARDS ASSOCIATED WITH THE WORK

Electricity and related hazards Dangerous chemicals to be used

Open flames or arc will be generated Work adjacent to normal work area
Crane Operation Noise will be generated
Moving machinery Safety Systems bypassed or disabled
Dangerous gases Chance of excavation collapsing
Trapped pressure Flammable or combustible
Flying Particles of sparks Any Others:

Danger of failing from heights ( Pl Specify)

PLEASE TICK THE PRECAUTIONS THAT ARE TAKEN DURING THE WORK

A GENERAL
1 Understanding of safe work-procedures by all workers and that they are trained to carry out the Yes No NA
required work
2 Establishment of proper and effective communication system and dissemination to the workers Yes No NA

3 Adequate illumination at all levels Yes No NA

4 Inspection of work-area prior to stating of the job Yes No NA
5 Providing workplatforms of adequate strength and ergonomically suitable. Yes No NA
6 Work at more than one elevation in the same location is restricted. Yes No NA
7 Ensure access is prevented to unauthorised personnel š Yes No NA
8 Ensure Scaffolding & working platform is provided of appropriate sizes Yes No NA
9 The Area has been isolated / cardoned off and signage placed to avoid hazards Yes No NA
10 Standby person available on ground Yes No NA
11 All ladders inspected and are in good condition for the proposed work Yes No NA
12 Securing of ladder (ensure proper slope) / scaffolding to prevent slipping, sliding or falling including Yes No NA
any tying required
13 Proper hand-rail/guards provided in ramps. Yes No NA
14 Walkways, aisles & all overhead workplaces cleared of loose material. Yes No NA
15 All PPE is worn (Use of safety helmets, Fullbody Safety Harness etc.) Yes No NA
16 Anchoring points at all places of work. Yes No NA
17 Provision of common life–line wherever linear movement at height is required. Yes No NA
18 Use of Safety nets wherever required. Yes No NA
19 Proper fall arrestor system at critical work places. Yes No NA

TIME PERIOD FOR WHICH THE PERMIT IS REQUIRED

Date from: Date to:

Time Window:

Risk Assessment Done: Yes No NA

(Please attach a copy of Risk Assessment Report)

CONTRACTOR'S ACCEPTANCE AND UNDERTAKING

I hereby declare that no work other than that stated above will be carried out, and all precautionary measures and other applicable health & safety
requirements & guidelines will be adhered to. I also certify that all the associated systems / circuits are electrically isolated, earthed if necessary
and all other relevant measures have been taken to ensure that the work and/or tests can be performed in a safe manner.

(Name of the Contractor / Authorised Rep) (Signature) (Time & Date)

APPROVAL

(Name of the Estate Manager / Authorised Rep) (Signature) (Time & Date)
CANCELLATION
I have inspected the work and hereby cancel this work permit for the following reasons (please tick as applicable):
Emergency called at site Any Other Reason (Please specify)
Safety guidelines are not followed
Tools & tackles are not safe

(Name of the Estate Manager / Authorised Rep) (Signature) (Time & Date)
COMPLETION
I hereby declare that the work stated above has been fully completed. I have inspected the work and hereby close this work permit. Following have
been checked & confirmed (please tick as applicable):

Work completed as per safety & other guidelines & all systems restored to normal operations
Work area is cleaned & secured
Guards are provided on all equipment
Smoke detector covers are uncapped
Fire Protection and Alarm Systems are made normal
LOTO system is removed

(Name of the Contractor / Authorised Rep) (Signature) (Time & Date)

(Name of the Estate Manager / Authorised Rep) (Signature) (Time & Date)

Note: All other applicable w ork permits such as hot / confined space / general shall also be obtained along w ith this permit by the
contractor prior to commencement of w ork.