ELECTRICAL PERMIT TO PTW No.

WORK High Voltage Low Voltage

This Permit only applies to the area/work specified below. Parts 1, 2 & 5 to be completed by a Senior POWRA/JHA/ST5/FLHA #
Authorized Person as Issuing Officer. Parts 3 & 4 to be completed by the sub-contractor or person undertaking
the work.

Part 1 - Authorization to Work

Location:
This permit is issued
Issued to:
by:

Employed by: Employed by:

For work on the

following equipment:

Part 2 - Declaration
I hereby declare that the apparatus detailed in Part 1 above is safe to work on and any adjacent live equipment is protected against accidental or
unauthorized contact. All other apparatus is to be treated as ‘Live’

List Points of Isolation

List Grounding / Earthing

Points

Nearest live equipment:

LOTO Lock Numbers:
Workplace clearly identified and safety notices posted? Y N
Circuit disconnected and secured against re-connection? Y N
Installation verified as dead? Y N
Circuit correctly earthed or grounded? Y N
Access to nearby live parts prevented? Y N
Auxiliary/Secondary sources considered and verified? Y N
Has Customer Responsible Person been identified? NAME: Y N
Above controls verified with the Customer Responsible Person? Y N
Have specific emergency procedures been established? Y N
Has pre-job briefing been held and has this permit been walked down with all parties involved? Y N
*Any above question answered no must be taken to a higher level of authority for clarification.

Summary of Work to be carried out:

Provide details of any special precautions required:

Signature of Senior Authorized Person: Signed:

Company: Print Name:

Time of Issue: Date:

ECAP Electrical Permit to Work – Feb 2021

 Part 3 - Receipt

I hereby declare that I have read and understand this permit to work. I am fully conversant with the nature of the work to be undertaken. I accept
responsibility for carrying out the work on the apparatus described as being safe to work on and no attempt will be made by me or any person under my
control to work on or interfere with any other apparatus.

Signed: Print Name:

Company: Time: Date:

Part 3A - Working Party Control

Briefing Time Time Time Time
Name Date Signature Signature Signature Signature
Received On Off On Off

Part 4 – Checklist for Hand-back by Recipient

Removed all tools, equipment, people, and material Y N
Removed all signs/barricades/flashing beacons used for marking the work area Y N
From this point the installation should be regarded as live
Clearance:
The work is complete, the equipment is cleared for return to service Y N
The work is incomplete, the equipment shall not be returned to service Y N

Part 4A – Hand-back

I hereby declare that the work for which this permit was issued is now suspended/completed. All persons under my charge have been
withdrawn and warned that it is no longer safe to work on the apparatus detailed on this permit to work and all tools and equipment and
temporary earthing/grounding arrangements (where applicable) have been removed.

Signed: Print Name:

Company: Time: Date:

Part 5 – Cancellation
This safety document is now cancelled
Signed: Print Name:
Company: Time: Date:

Part 5A – Checklist prior to Re-energisation

Before re-energizing ensure no person(s) remains in the danger zone
Uncovered or removed protection of adjacent live parts? Y N
Removed earthing/grounding and short-circuiting? Y N
Removed all locks or devices, which were used to prevent re-energization? Y N
Inspected by SAP to confirm that the installation is ready for energizing? Y N
SAP hands over the installation to the Plant/Site responsible person? Y N
Uncovered or removed protection of adjacent live parts? Y N
Supporting drawings and instructions should be documented on a separate sheet and attached to this document.

ECAP Electrical Permit to Work - Feb 2021