wl AN Format PERMIT TO WORK

Rof No
BDC/BYTE/DIGHAHoighiWorkPTWNO 26
Permit To Work- HEIGHI WORK
Permit Appicant Mahe nara Pawa1 Exact Location UR 1¬R DATA hAL
Pe'son Responsible For ENecution ot the Work (Name. & Comparny)
Name Of Contractor VK BS C) b ) S103

ype and Scope of work-VS.n.. iPe nslalfadvan

Work Permit Validity Scu ngh01e
21 571al 1&
Desired Date & T ime DTS te &Time Of do}Pormit Extonslon Pormit Appllcant | Work Roloasu Authority
Expiry
Applicant mahe ndra laLU Date / ime / Sign
Name in biock letters)/date/ signature Date / Ime /
Sign
Note: general maximum validity of a work pemit shall not be
eceed 1 (onel day H o w e v e r in c a s e o f e x t e n s i o n r e q u i r e d
Date / Tme / Sign
4 nzaton as above is MUST"
HEIGHT WORK Chock Points
Any work on, below, or above ground lovel where there is risk ofporsonal injury through falling andor a potontial risk to poople
below the work site being injured by falling objocts.s.

Sr No Measuree Remarks
TB to workmen regarding hazards and working procedure conducted (Attach
Atenddhce)
YES NIA
NOuticaion to other Ikely aftected contractor personnel YES NIA
Approved Method Statement & Risk Assessment available for the activity YES NIA
Personne provided with full body harness, fall arrestor & life line YES N/A
Ladder ana scaftold secured and supported propely, Inspected and tagged YES NIA
Weather condition nomal ( Check for slippery surfaces, high wind pressure etc) YES NIA
Working platform with full decking. double railing, access ladder, bracing. toe board,
YES N/A
base platewneellock etc Provided
Woring area bellow safely baricaded and Caution signages installed YES N/A
Area aroung the workplace cleared and all scraps removed after complitton of work YES NIA
All toois are fit and properly anchored and carried in bags/ tool kit.
YES NIA
Vertical and horizontal catch net provided below progress
fioor. YES NIA
Competent Supervision available at the place at all time YES NIA
Whether illumination of mim 50LUX maintained at the work location. YES NIA
Crew is trained and competent for the work and Height Work Pass issued to all the
workers working at heign YES NA

5 Any otner Precautions taken-

TickAs Applicable
Barrcades warning signs LBanksman/Flag man/ Helper Illumination Escape route kept Ciear
Satety harness ith ifeline LEquipments/ Hand tools Fittness Fire Extingusher
Eye protection
Supervision
Competent Operator Resp1rators/ Gas mask Risk Assessment
PPE's Ventilation First Aid Metnod Statement
Earthing mergency Vehicle Weather Condition Medical Fitness
Otner (Ple ase Spec1fy)
Additional Safety Precaution/ Remarks

Component to Isolation List YES

be isolated If Yes Special
-

measurelrequirements
1. Energyto be isolated Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls Specify
2. Method of Isolation
3. Type & No. of LOTO device
4. Person responsible for Isolation (Name & Sign) 5.If shiftchange.person responsible for Isolation - (Na
Execution Of confirm that l have been given charge ofthe above mentioned work and I will take all necessary precaution to avoid
Work danger to the workers engaged at the above site as well as property. I will abide by the recommendations of the safety
engineer and implement them and will assign jobs to only trained personel

Mahe uea uwur 1221212 | 9:3c Mobile No GIC?CraG

Authornzed Applicant of Contfactor ( Site Engineer)
(Name/date/time/signature)
 Check of EHS Identified EHS measure isolation actions:
/ The
precaution and safe condition mentioned
Measure and&satisfactory and allowed in checkpoints have boen vorified
to work
solation Action

mLLind Shvima
Contractor EHS Engineer / Manager:
Name /date/ signature
Work Competent Eng1neer/Supervisor assigned and
necessAy safety precautions facilitated The work
Authorization is authorized to start
From Diwan si n) h
Contractor Mobile No
Respective site managerl area inchai (Name /date/ signdture)
Additional Safety Precaution / Romarks
Work Release
Authority Venfied Checklist/ isolation
action and specific
PMC
EHS measures

( Site
1 2 1 Ny Aute TV
manager / area inchragd ) Name ( in block letters)/ datel signature

Tme HSE COncerns

Random Recommendation Inspoctod by( Sign and Name)
Inspection by
HSE

Work completed as specified :

"Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Completion
Applicant of Contractor
( Site Engineer) Name date / time/ signature
Person responsible for Isolation
Name ( in block letters)/date /tume / signature
Physical venification of the closure of work Is
mandatory for sign off by work release authority Work Completion Handover:
Notification of PMC (Site Managerl Area Incharge)
In case of
Completion energy Isolation, shall verify the completion|
of work, ask for and verify the re-energisation and
off the permit after sign Name
re-energisation ( in block letters)/date / tume /
signature

only requred for isolation; like underground public/ private utilities , overhead underground HT/ LT electric supplylines etc
-

PMC Safety engineer is authorized to visit and check

cross safety measure at permit locations and in case of
non-adherance
can STOP the work

aeo fauou
( Duoyn PuUOm
( Muda@g lclhontn

Atala