Yes No N/A Yes No N/A

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Competent Supervisor to Oversee the Work Yes No N/A

Required PPEs Provided? Yes No N/A

'D' AUTHORISATION TO WORK

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.

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