ELECTRICAL WORK PERMIT (HT / LT)

PLACE OF WORK ______________

GROUP ______________
DATE ______________

Name of the person taking Shutdown / Power Block ____________________

Designation _____________

Why Shutdown / Power Block required ______________________________

_____________________________________________________________

Apparatus / equipment on which shutdown required ___________________

Approximate time of shutdown / power block from _______ hrs to ______ hrs

Signature ___________
Person taking shutdown

Action taken to make the apparatus safe to work ______________________

_____________________________________________________________
Earthing done ______________________
Caution tag placed at _________________

I declare that apparatus / equipment mentioned above is safe to work and shutdown
is given and the same will not be made alive till the permit is cancelled in writing by
the person taking shutdown.

Name of the person issuing shutdown _________________

Signature _________ Designation _________ Date _______ Time ________

I declare that the work has been completed and men and materials have been
removed from the place of work and apparatus / equipment is safe for starting

This shutdown is hereby cancelled

Name __________ Signature _________ Date ________ Time ________

Note: Form should be made available in three copies. Persons taking shutdown
should have two copies with him. One copy should be retained for documentation
and another copy to be handed over to person giving shutdown after job is
completed.