Permit No:- Date:-

Date of Issue:- Work Day & Date From :- To:-

Project Name:- Cost Canter:-
Exact Area/Location:-
Type of Work:-
Detailed Description of Work to be Carried Out:-
'B' DETAILS OF RESPONSIBLE PERSON CARRYING OUT WORK:-
Name of Person Permit Issued To:- Vender Name
Contact No:-

'C' SAFETY PRECAUTIONS

Risk Assessments Provided ? Yes No N/A
Safe Work Method Statement Provided? Yes No N/A
Local Emergency Procedure Explained Yes No N/A
Competent Supervisor to Oversee the Work Yes No N/A
Required PPEs Provided? Yes No N/A

Name 0f the Person Working Gate Pass No Name 0f the Person Working Gate Pass No

'D' AUTHORISATION TO WORK

I hereby declare that the necessary precaution have been put into place and that work specified in part 'A' is
authorised to commence.

Signed (Building Engg.) Name of Building Engg. Date Time

'E' ACCEPTANCE

I hereby declare that I accept responsibility for carrying out the holiday work detailed in part 'A' of this permit and
that no attempt will be made by me or by persons under my control to work in any areas. Appropriate safety
precautions will be taken at all time.

Signed (Vender representative) Name of Contractor Date Time

Project Incharge Safety Dept. Security Dept.