PERMIT TO WORK

CONFINED SPACE
Project Name : ……………………………
Permit No : ……………………………

Applicant Detail
Name of Contractor : Name of Person entering: Signature Name of standby man: Signature

Tel No : 1) 1)
Person in charge/Competent person : 2) 2)
Location of confined space : 3)
Duration of work : 4)
Entry/expiry date: ______________ Time start: Time end:
Description of work to be performed:
_________________________________________________________________________________________________________________________________________________

Signature : Name :
Position : Date :

Equipment Required For Entry and Work

Yes No Yes No Yes No
Respirator Communication aid Hearing protection Others ______________________
Lifeline/harness/retrieval equipment Monitoring equipment Safety glasses/face shield ______________________
Protective clothing Fire extinguisher Low voltage tools/equipment ______________________

A test for presence of: Percentage Pre-Entry Checklist Yes No

Oxygen The space to entry is free from flammable items/toxic & present oxygen?
H2S Isolate or blinking off or disconnected from every source of service?
CO Is it not connected from motive power?
Combustible The means of entry and exit to the confined space will be via
A rescue plan is necessary and has been provided by contractor?
Is road to be blocked or closed due to under ground space work?
Is emergency apparatus ready for emergency usage?

Pre-entry checklist Yes No Remarks

SWI Issued Issuance Date :
SWI briefed to all workers Briefing Date : I have checked both the job and the permit. I understand the nature and extent of the work and the
SOP (attachment) issued Issuance Date : precautions and procedure to be followed in completing the work safely:
SOP followed Verification Date:

Description Name Date Time Signature

Checked By (Work Supervisor)
Checked & Verified By (Safety Personnel)

Doc. Ref. : PCD/OSH/SF/35 Rev. No. : 3 Effec. Date : 01 April 2019 Page 1 of 2
 PERMIT TO WORK
CONFINED SPACE

Validity of Permit
This permit is valid for max 12 hours working days

Renewal (if applicable)

No Date Time valid until Authorized Signature Checked By (Work Supervisor) Date Checked By (Safety Personnel) Date Remarks

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Doc. Ref. : PCD/OSH/SF/35 Rev. No. : 3 Effec. Date : 01 April 2019 Page 2 of 2