MECHANICAL WORK PERMIT

Project Name: Permit No.:

Date: From: To: Duration (Time): From: To:
1. Details of Work:
1.1 Name of Company:
1.2 Location of Work:
1.3 Description of Work:

1.4 Person in Charge (supervisor): No. of Workers:

1.5 Equipment & Tools
to be used:
Fire Hazard Fall From Height Slip, Trip, & fall hazard

2. Hazard Dust / Suffocation Entanglement Drawing in or trapping

Considerations
Electrical Shock Hazard Impact Traffic collision/ disturbance

Additional Hazards to be present: (for further, you may use back side of this page):

Fire Extinguisher Face Shield/Goggles/Mask Lock out/Tag out

3. Precautions &
Fire Protection Wear Full Body Harness Avoid Loose Clothing Complete Working Platform

Additional Precautions to be taken: (for further, you may use back side of this page):

4. Atmospheric Test: Gas test required? Yes No If yes record the results below
Name Time Flammable 0% LEL Oxygen 23.5%-19.5% H2S Signature

Remarks Regular basic PPE, availability of adequate supervision, method of statement, & risk assessment, etc., are mandatory.
Person Authorized Permit Name Position Sign Date
Permit Receiver from Sub-Contractor:
Permit Issuer from HHI:
Tick Permit Statement Person Name Sign Date

Permit date is finished, job is still not Request (Receiver)

finished, Please extend the date of the Approved (Issuer)
Permit Permit extended up to:
Request (Receiver)
Permit is closed, job is completed
Approved (Issuer)
Permit Cancellation:
Cancellation Remarks:
Cancellation Requested By: Authorized By:

HHI-PTW-01, REV-00
HHI-PTW-01, REV-00