CONFINED SPACE PERMIT

Name/ Identity of the Site:

Project Code:

Location of Job: Purpose:

Name of the Contractor:

Start of Work ________ ___________ End of Work ________ _______

Date Time Date Time
A. Type of Work:

Arc Welding Grinding Gas Cutting/ Welding

Gouging Heating Installation
Inspection Cleaning Any Other

Not
S.No Points to be taken care Yes No
applicable
Is all the Utility lines , Gas lines, Electrical supply and Other
01 lines related with the Confined Space has been Isolated and
Tag Provided?
02 Is the Confined Space Purged and cleaned?
Have all the persons required to enter the confined space been
03
trained in dealing with the specified hazards
Have a Rescue team equipped with rescue devices put on
04
stand by.
05 Were all the Gas Monitoring devices calibrated?
06 Have 24V lamp been provided
07 Exhaust system provided?
08 Fresh air Supply/ Flow Provided?
09 Availability of Fire Fighting Equipments in the site?
10 Emergency Exit Availability or Provision
Test Required
01 Oxygen level (19.5% - 22.5% by volume). Mention ________
02 Explosion (0%)
03 Carbon Monoxide level (<50 PPM). Mention_________
04 Carbon Dioxide level (1200PPM)
05 Dust availability
06 Temperature Inside the Confined Space. Mention________
07 Air Flow sufficient
08 Others

Tests Conducted By:

 Contractor Engineer/ Supervisor:

Name ______________________ Signature______________ Date & Time _____________

Mobile No. ____________________

Siemens VAI Engineer:

Name ______________________ Signature______________ Date & Time _____________

Mobile No. ____________________

B. Number of Persons working for this Job: ________________________

C: PPEs required during work

a) Welding Shield b) Gas welding Goggles c) Leather Gloves d) Grinding goggles e) Helmet
f) Leather Apron g) Full Body Harness h) SCBA ( Self Contained Breathing Apparatus) i) Oxy-Pack
j) Gas Masks k) Dust Masks l) Ear Plugs/ Muffs j) Any Other

D. Tool Box Talk Conducted Yes No (Attach with the Permit along with attendance sheet)

E.I Confirm that all the above mentioned measure have been taken to avoid dangerous occurrences. Only
trained workmen will be assigned for this work.

Permittee (Working Agency/ Contractor)

Name ______________________ Signature______________ Date & Time _____________

Mobile No. ____________________

Contractor Site Safety Officer

Name ______________________ Signature______________ Date & Time _____________

Siemens VAI Site In-charge

Name ______________________ Signature______________ Date & Time _____________

Siemens VAI Site Safety Officer

Name ______________________ Signature______________ Date & Time _____________

F. Safety Measures on Completion of Work:

Yes No
a) Waste Cleared from Work site.

b) All Men and Material is removed from Site

c) Site is Safe to restore the power

d) Signature of Contractor Official while doing above work ____________________-

G. Permit Closure:
 Name of the
Permit
Closing Name of the
Date &
S.No authority Signature Engineer Signature Remarks
Time
(Siemens (Contractor)
Site In-
charge)

H. Permit Renewal (To be signed by Permit Issuer)

Name of
the Permit Signature Signatur
Date Renewing Name of the of e of
S.No & authority Signature Permittee Signature Contractor Siemens Remarks
Time (Siemens (Contractor) Site Safety Safety
Site In- Supervisor Officer
charge)

 Note: This permit is Valid for that Particular day work i.e. from 8AM- 8PM.After completion of work, permit
to be returned to the concerned Siemens VAI Engineer or Safety Officer for closing the Permit for that day.
 If the same is to be continued, permit must be renewed for further commencement of work