Document No.

GE Renewable Energy – Hydro - RSP RSP_W I0573

Permit To work Request

A. General data (to be completed by the Permit Requester)
WHO: (personal details of PTW Requester)
PTW Requester Name: PTW Requester Company:

WHAT: (description of the activity to be completed – Attach document whenever necessary for further description)

WHEN: (requested start time and duration for the activity – max one shift for radiography, 15 consecutive days for other
activities)
Proposed Start Date and Time: Proposed Duration:

WHERE: (precise location(s) of the activity, including equipment / system name and KKS reference if relevant. Provide layout)

HOW: (specific equipment used impacting the safety of the activity)

ATTACHMENTS
 Risk Assessment  Lifting Plan  Ventilation Plan  Radiography Preparation
 Method Statement  Rescue Plan (W@H, CS)  Hazard Id. Survey  Drawing / Layout
 Refer to RA/MS n°:  Others:

HIGH-RISK ACTIVITIES INVOLVED

 Excavation works  Works with exposure to radiations (ionizing or non-ionizing)
 Works at heights  Works involving a risk of interference with moving vehicles
 Works in confined space  Lone working
 Lifting operations  Works in potentially Explosive Atmospheres
 Hot works  Erection, modification and dismounting of scaffolds
 Works on/near live equipment  Works above or under water
 Works for which LOTO must be performed  Works requiring the use of hazardous substances
 Works on systems handed over to Commissioning  Pressure testing
 Other:……………………………………………………………………….  Installing, Servicing and Operating machines
B. Permit to Work Request Deposit (to be completed by the Permit Requester)
I confirm hereby that all the above-mentioned information is accurate and relevant at the time of this request.
Signature: Date and Time:

C. Permit to Work Request Acceptance (to be completed by the Permit Authorizer)

Decision regarding Request:  Authorized  Authorized with modifications (number of modifications:………) 
Rejected
Additional Requirements:

Full name: Signature: Date and Time:

D. Permit to Work Request Receipt (to be completed by the PTW Engineer)

PTW Request received on: (Date, Time) PTW Request received by: (Name and Signature)

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