Permit no.

SAFETY WORK CLEARANCE

Project: Emergency Contact Nos:

HSEP:12-F04 BHEL Sub-contractor:

CONFINED SPACE ENTRY PERMIT

Area of work: ___________________________________________ Date: ________________________ Time: ______________
Name of Sub-Contractor Site Engineer (Permit Requesting Authority): ____________________________ Sign: _____________
Name of Work Performing Contractor: ________________________________________________________________________
Name of Package In charge: _____________________________________ Sign: ___________________ Date: _____________
Description of Work: ______________________________________________________________________________________
_______________________________________________________________________________________________________
Duration of Work Execution*: From Time: _____________ Date: ______________ to Time: __________Date:________________
The above signing person(s) will be responsible to ensure that the above described work will be done under all the safety
precautions mentioned on the permit to work.
The following precautions are to be taken:
Not required /
No. Item Yes Remarks
1. Has the equipment been Isolated from Power/Steam/Air?
2. Has the equipment been Isolated from liquid or gasses?
3. Has the equipment been de-pressurized &/or drained?
4. Has the equipment been Blanked/blinded or disconnected?
5. Has the equipment been water flushed &/or steamed?
6. Whether man ways open and ventilated?
7. Whether constant Inert gas flow arranged?
8. Whether mechanically ventilated and adequately cooled?
9. Whether 24 V lighting provided inside the confined space?
10. Whether Radiation sources removed?
11. Whether training on confined space provided to the group?
12. Whether required PPEs (hand gloves, goggles, face shield, ear plug/muff, protective
clothing etc.) used?
13. Whether Safety harness and Lifeline used?
14. Whether Dust/Gas/Air Line mask used?
15. Whether attendant with SCBA/Air mask available?
16. Whether grounded air Exhaust/Blower/ AC provided?
17. Whether Personal Gas alarm provided?
18. Whether communication Equipment Provided?
19. Whether rescue equipment/team available?
20. Whether firefighting arrangement done
21. Others:

Name of Sub-Contractor Safety Officer: ____________________________ Sign: ______________ Date: ________ Time: _____

Reviewed and approved by BHEL Site Engineer (Permit Issuing Authority):

Name: _________________________________________ Sign: _____________________ Date: ____________ Time: ______
Name of BHEL Safety Representative: ______________________________________________ Sign: ____________________
I understand the precaution to be taken as described above and as per project requirement and hereby confirm that work will be
executed under my supervision by following all precaution and Safety Rules.
Name of Work Performing Authority: ________________________Sign: _____________ Date: _________ Time: ______
Permit Cancellation / Closure:
I hereby declare that the work is cancelled/complete, all workers under my control have been withdrawn and the site restored to
safe tidy condition.
Name of Work performing Authority: _______________________________ Sign: ____________ Date: ________ Time: ____
Name of SC Site Engr. (Permit Requesting Authority): _____________________ Sign: ____________ Date: ________ Time: ____
Name of BHEL Site Engr. (Permit Issuing Authority): ___________________ Sign: ____________ Date: ________ Time: ____

(* Permit valid subject to daily renewal as per overleaf instructions)

Original at BHEL site Second Copy – BHEL SAFETY Third Copy:BHEL Sub-Contractor
 PERMIT RENEWAL

Extension Period
Signature of Contractor Signature of Contractor
Sl. No. (Date) From…….. (Time- Hrs) From……..
Site Engineer /BHEL Safety Officer
To……….. To………..
1.

2.

3.

4.

5.

TO BE SIGNED JOINTLY BY THE CONTRACTOR HSE & EXECUTION AFTER THE WORK IS OVER
Permit is here by returned / closed after completing the job.

Site Engineer, Contractor Site HSE Engineer, EPC Contractor

Certified that the subject work has been completed Certified that the subject work has been
/stopped and the area cleaned. completed/stopped and the area cleaned.
Signature (With Dt. & Time): Signature (With Dt. & Time):

Name: Name:

General Instructions:

1. Permittee to observe precautions as mentioned on pre-page, mentioned by concerned discipline

coordinator.
2. Permit must be available at the site all the time during work with permit receiver.
3. This Permit is valid for maximum7 days or as indicated. Every day permit shall be renewed before
start of the shift by EPC contractor both HSE and Site Engineer.
4. Work location to be constantly supervised by Contractor and BHEL HSE and Execution, to ensure
precautions as per this Permit and other HSE requirements