LOTO PERMIT (A)

System / Component Safety Tagging Permit (LOTO Office)

PTW Details
Permit No: Location
PTW Requestor
Name Name
Designation Designation
Signature Signature
Entity Electrical Mechanical Testing & Commissioning
PTW Validity
PTW Validity From To Date
Reason for PTW Request (Detail Description)

Note: This Permit should be considered suspended, if any emergency declared at site. This permit will be valid for One
working shift and could be extended by Permit Issuer, on request from Permit Requester. Extension of permit should
not be (for) more than one additional working shift, and up to Six consecutive days. Extension sheets should be used
for, permit extension and, if needed to record locks/tags details. Permit issuer endorsement is mandatory, prior to start.
Work should be carried out as per approved procedure/method statement.
Approved by tagging Authority
Name
Designation
Signature
Date
PTW Closed by:
Tagging Authority Tagging Authority
Name Name Name
Designation Designation Designation
Signature Signature Signature
Date & Date & Date &
Time Time Time
 LOTO PERMIT (A)
System / Component Safety Tagging Permit (LOTO Office)

Checklist to be filled by Permit Requester

Description Yes () NO (×)

Method statement is in place?

Job safety analysis in place?

Is there safe access to

workplace?

Adequate signage’s displayed?

LOTO officer inspected the

workplace?

Task briefing delivered by

technical engineer to all
involved workers and signed?

Is the workplace safe from

environment risks?

Area is barricaded to avoid

unauthorized entry?

All necessary precautions

taken/STARRT completed,
prior starting activity and
verified by LOTO officer?

All equipment and devices are

free from damage?
 LOTO PERMIT (A)
System / Component Safety Tagging Permit (LOTO Office)

EXTENSION REQUEST EXTENSION PERMIT REQUESTER PERMIT ISSUER &

TIME & DATE VALID UP TO SIGNATURE HSE Dep. SIGNATURE

Permit Extension Sheet

 LOTO PERMIT (A)
System / Component Safety Tagging Permit (LOTO Office)