GENERAL PERMIT HIGH RISK ✔ FEB23-P042

PERMIT DETAIL SERVICES BEING WORKED ON

Description of Work: Hazards - Tools & Machinery
Test Power tools & Machine Safety Cranes and lifting equipment
Forklifts & Powered Industrial Vehicles Hand tools ✔
Hazards - Other
Start Date of Work: 23/02/2023 Finish Date: 23/02/2023 Please detail any other hazards: NA
Start Time of Work: 2:00 PM End Time of Work: 3:45 PM
Location of Work: IN-BLR-BCPV Level: 8 Block: PRECAUTIONS & PPE

Please Specify Location (Levels/Meeting Rooms/Office Name/ID): Lockout/Tagout required? No

aaaa Precautionary Measures when setting up
IMMEDIATE WORKS Use of warning signs Use of barriers/cordon off area Fire alarm & sprinkler isolation ✔
Special Access Required? Yes Obtain radio from Security (if working in basement, window cleaning cradles, roof or lone working)
Server Rooms ✔ MV switches ✔ UPS room ✔ COMPANY QUALIFICATION REQUIREMENTS
Makers Workshop/laboratory Plant room Roof • Google Bangalore Site Induction
Mitkat Test Company
Nature of Work to be carried out
Installation Breakdown ✔ Maintenance Commissioning DOCUMENTATION REQUIREMENTS
Events Office equipment moves Catering equipment maintenance Other
Construction Project (applicable if more than 500 days or 30 working days)
PSDP Name: PSCS Name:
Manual Handling with condition (below 20kg) Specify if “Other”:
PPE PERMIT MONITORING
Type of work
Y N N/A Comments
Working at Height ✔ Manual Handling with condition (above 20kg) ✔ • Face Mask
Are copies of safe systems available Time of check:
• Hard Hats with contractor at work area?
Mobile Elevated Work Platforms Roof Work Ladders/Access Equipment ✔ • Face Shield Is the required PPE being worn in a Time of check:
External Window Cleaning / Cradle Fall Arrest Equipment Scaffold Tower • Eye Protection correct manner?
• Hearing Protection Are required controls, as per safe Time of check:
Excavation Hot Work ✔ Confined Space systems, (such as barriers etc) in place?
Are hazardous substances being used Time of check:
Boiler & Pressure Systems Electrical in a safe and correct manner?
Are waste / environmental items Time of check:
SERVICES BEING WORKED ON being managed correctly?
Checks against work practices and safe systems – Considering the work involved and on reading the
Are services being worked on? Yes method of work detail below select elements you wish to check for compliance (note: the minimum is
one check per task carried out, but more are recommended dependent on activity complexity)
Electrical Mechanical HVAC BMS Sprinklers
COLUMN A COLUMN B
Fire alarm systems Working with Elevators/Lifts/Scaffolds/MEWP Detail below the item or part of the method of Detail below if check identifies that all works are
work being checked being carried out correctly, or what was found to
Emergency lighting systems Water tanks - cleaning and chlorination be non conforming to requirements
Check 1) Detail of check made:
Fall Protection Systems Roof Membrane Work with Gas mains or piping ✔ All in order: YES / NO
Enter time of check: COMMENTS:
Works impacting on the Fire Suppression Systems such as sprinkler impairment ✔
Check 1) Detail of check made: All in order: YES / NO
Hazards - Environment COMMENTS:
Enter time of check:
Hazardous Substances ✔
Check 3) Detail of check made: All in order: YES / NO
Hazardous Waste Lead Asbestos Chemical Safety ✔ COMMENTS:
Enter time of check:
Electricity ✔ Noise Pressure vessels ✔ Slips/trips/falls
Monitoring carried out by (Name): Signature: Date:
Movement of Pedestrians & Vehicles/Machinery Laser Safety

Page 1 of 3
Manual Handling

GENERAL PERMIT
• Remember to use safe lifting practices
• Use mechanical means when possible to move heavy loads FEB23-P042
• Don't lift alone, get help if needed
SAFETY REQUIREMENTS TOOLBOX TALK (TBT) ATTENDANCE RECORD - To be completed before work commence
Work Zone
• Notify personnel in the immediate vicinity Discussion to be completed:
• Follow your company's Hot Work Program as required Emergency Evacuation Route & Plannings YES / NO
• For more information on Google 's Hot Work Policies, visit go/Hotwork
• Assure a safe work zone is established with signage or caution tape Personal Safety & PPE YES / NO
• Post this work permit in visible location Incident Reporting YES / NO
• Review posted building evacuation map
• Follow all safe work practices established by your company Tools & Equipment Used on site YES / NO
• Locate the closest First Aid cabinet and AED unit Job Specific Details YES / NO
• Use all PPE required for your job
Others (Please Specify):
• Contact your Google Host if new or changed hazards are presented YES / NO
Electricity
• Work can only be performed on de-energized systems unless specific authorization has
been provided prior to the start of work Name of Workforces Workforces TBT Time
Date Of Work
• Follow your companies Electrical Safety Program Attended TBT Signature Conducted By Conducted
Emergencies
• Fire, Medical or other Emergency requiring emergency responders Call Google Security
(GSOC) +1 650-253-5555
• Immediately contact your Google Host

Server Room
• Only authorized personnel allowed in Server Rooms
• No photography or recording is permitted
• Follow your company's safe electrical work procedures

Electrical Work Details

• For more information on Google 's Electrical Safety Policies, visit go/electricalsafety

Fire Watch
• Must be present when necessary

WORKFORCE SELECTED
Aniket Ghosh

Should you have any other information or enquiries, please input here:
Test permit

Page 2 of 3
 GENERAL PERMIT FEB23-P042
HIGH RISK WORK CHECKLIST - To be completed at the jobsite AUTHORISATION - You must only sign if you agree with the statement below
Hot Work - To be completed at jobsite I confirm that I have reviewed the risk assessment and any supporting written safe system of work
• Will any part of an installed sprinkler/gas floor or similar fixed fire installation be affected by the against the specific work mentioned above and I am satisfied that all the necessary precautions are in
activity. [__] Yes [__] No [__] N/A
place to effectively manage the risks
• Has smoke/fire detectors equipment been isolated or otherwise prevented from operating? [__] Yes
[__] No [__] N/A Permit Approver Name:
• If the above is YES, confirm the integrity of adequate fire precautions are maintained and have been
approved? [__] Yes [__] No [__] N/A Siva Soumya Narapa Reddy
• Suitable extinguishers (other than those installed at Google) and/or fire blanket specifically been
provided at the work scene? [__] Yes [__] No [__] N/A Work Requester Name: Signed: Date/Time:
• There is an adequate means of raising the fire alarm, especially if local system is isolated; full details
should be in risk assessment? [__] Yes [__] No [__] N/A soumya
• The area is clear of combustible materials, flammable liquids, flammable liquid containers and vessel/
lines are purged and clear? [__] Yes [__] No [__] N/A Contractor Name: Signed: Date/Time:
• Adequate precautions are implemented to ensure flammables are completely protected from fire risk
including gas cylinders/hoses? [__] Yes [__] No [__] N/A
• Walls/floors including gullies, ducts, etc are suitably protected from exposure to flame? [__] Yes [__]
No [__] N/A CLOSURE
• The work causes conditions that affect systems under the control of others, they have authorised the Work Requester Name: Signed: Date/Time:
works and controls? [__] Yes [__] No [__] N/A
• The Person in Charge of doing work has been made aware all systems and work in the immediate soumya
vicinity of this work area? [__] Yes [__] No [__] N/A Contractor Name: Signed: Date/Time:
• Areas likely to be affected by the work have been sectioned off and alternative access routes
provided? [__] Yes [__] No [__] N/A
• Suitable warning signage has been displayed at all appropriate places and emergency exit routes?
[__] Yes [__] No [__] N/A PERMIT NOTES
• All other parties likely to be affected have been notified of the activity/works including any system
shutdown, etc? [__] Yes [__] No [__] N/A
• I am satisfied that other activities/critical systems related to this work have been identified and it is
safe to do the work? [__] Yes [__] No [__] N/A

Work at Height - To be completed at jobsite

• The competence requirements of those involved in the activity/work have been checked and
confirmed as adequate. [__] Yes [__] No [__] N/A
• The work causes conditions that affect systems under the control of others, they have authorised the
works and controls? [__] Yes [__] No [__] N/A
• All other parties likely to be affected have been notified of the activity/works including any system
shutdowns etc? [__] Yes [__] No [__] N/A
• Scaffolding is used and will: be erected, have a documented inspection daily and be dismantled by a
competent person? [__] Yes [__] No [__] N/A
• Window cradles etc will have: valid test certs (6 mths), competent operators, documented site and
task-specific risk controls? [__] Yes [__] No [__] N/A
• Ladders or steps are required (only as a last resort) they are confirmed as being of industrial
standard (EN131) and serviceable? [__] Yes [__] No [__] N/A
• Weather and underfoot conditions are safe and likely to remain so, to allow for safe working and
access at height? [__] Yes [__] No [__] N/A
• Weather and underfoot conditions are safe and likely to remain so, to allow for safe working and
access at height? [__] Yes [__] No [__] N/A
• Where the above is NO fall arrest equipment is required and test certs valid (6months), users
competent, risk controls documented? [__] Yes [__] No [__] N/A
• All ducts, drains, outlets, skylights, etc on the roof are noted and protected/isolated from risks (fumes
and trips and fall hazards)? [__] Yes [__] No [__] N/A
• Overhead services crossing over or close to the work area have been identified and adequate risk
controls implemented? [__] Yes [__] No [__] N/A
• Communications /RF/microwave equipment has been identified and adequate risk controls
implemented? [__] Yes [__] No [__] N/A
• Suitable warning signage has been displayed at all appropriate places and emergency exit routes?
[__] Yes [__] No [__] N/A
• I am satisfied that; other activities/critical systems related to this work have been identified and it is Page 3 of 3
safe to do the work? [__] Yes [__] No [__] N/A