ENERGIZED ELECTRICAL

WORK PERMIT

SAFETY

Chapter: Safety Fundamentals

Document Number: VPO.SAFE.3.1.07.05. Energized Electrical Works Permit Example
Revision Number: ________________
 Safety: Electrical Work Permit

Completion of this Work Permit is required EITHER:

Before any work on energized electrical equipment or components is started.
(Per Arc Flash training - Applies to anything over 50 volts that is not considered testing,
troubleshooting or voltage measuring)
OR
When ANY work is taking place on equipment with voltage greater than 600 volts. (High Voltage)

TYPE OF PERMIT: HIGH VOLTAGE ENERGIZED ELECTRICAL

Complete appropriate sections below. All required signatures must be received before the work can
commence.

Equipment Until work is

requested to be complete
Description shut down
Temporarily,
of Work (Specify how long while barriers
– OR Not are being
applicable) placed.

Planned Planned Time Out of Planned Time Back in

end date Service Service
Planned and
Date of Work time:

Equipment ABI Person

And Responsible for Work
Departments
Affected

Work Work Site Location:

Order/Projec (Building /
t No: equipment panel #)

Requested Titl Dat

Signature:
by: e: e:

In Case of Emergency: Call

Complete Below During Pre-Planning Meeting by electrically qualified persons performing the work.

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 Safety: Electrical Work Permit

Detailed Risk Assessment Questions – Energized Electrical

(from table 130.2 (c))

1. Shock Analysis/ Approach

Boundaries: ___Ft ___ in

Limited approach Boundary- ___Ft ___ in __ Work will be conducted within this
boundary.
Restricted approach Boundary-
Prohibited approach boundary-
___Ft ___ in __ Work will be conducted within this
boundary.

Arc flash boundary will be identified on the arc flash label.

2. Results of the Arc Flash Hazard If equipment is not labelled refer to NFPA 70E 2012
Analysis appropriate section of table 130.7 (c)(15)(a)
Arc Flash Boundary ___Ft ___in

3. Required PPE: ATPV rating (in N/A (Cat 0) 8 cal (Category 1& 2) 40 Cal
cal/cm2) for AR clothing: (Category 3 & 4)

40 Cal PPE Requirements

Category 0 PPE
(check required PPE for task)
Voltage-rated tools
Voltage-rated gloves
Safety glasses
Hearing protection
Leather gloves
Leather work shoes
8 Cal PPE Requirements
 Multi-layer AR flash suit
 Long-sleeve shirt AR 8
jacket
Cal
 Multi-layer AR flash suit
 Long pants AR 8 Cal
pants
 Coveralls AR 8 Cal
 Flash suit hood
 Balaclava
 Leather work shoes
 Hard hat & face shield
 Safety glasses
 Leather work shoes
 Hearing protection
 Safety glasses
 Voltage-rated tools
 Hearing protection
 Voltage-rated gloves
 Voltage-rated tools
 Leather outer gloves
 Voltage-rated gloves

4. Means employed to restrict the

access of unqualified persons from Signs/tags Barricades Attendants
the work area:

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 Safety: Electrical Work Permit

Shut down creates an increased/additional Date

hazard (specify):

________________________________________
5. Justification for live work _________
request:
Shut down is infeasible due to design or
operational limitations (specify):
________________________________________
____________________________________

Detailed Risk Assessment Questions – High Voltage

All questions must be answered “Yes” or “N/A” before any work can be
YES N/A
completed. Additional controls may be required.

1. A Disruption Notice has been issued for the planned work.

2. Kirk-Key Interlocks are involved and procedures for their use are
understood

3. Confined Space entry is required and procedures for such entry are
understood.

4. The LOTO SOP has been reviewed and is current.

List SOP Name(s) and Number(s) :

5. Switching procedures to be used have been identified.

Provide outline in Additional Control Methods section or Attach Summary

6. The Zone Power Group has been contacted and comments regarding this
work have been received.

7. All special tools required to safely conduct this task have been identified.
(List the tools in Additional Control Methods section)

8. All special precautions required to safely conduct this task have been
identified
(List precautions in the Additional Control Methods section.)

Refer to the Electrical PPE Matrix:

100 Cal Suit Face Shield Safety Glasses High
Voltage Rated Gloves

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 Safety: Electrical Work Permit

Hard Hat Flame Resistant Coveralls Mats

Insulated Tools
Barriers Non-Conductive Footwear Hearing Protection
EMRT Notification Planned Other (Specify)

Detailed Risk Assessment Questions – ALL

All questions must be answered “Yes” or “N/A” before any work can be
YES N/A
completed. Additional controls may be required.

1. Has a documented job briefing with detailed procedures been conducted?

2. Have personnel been properly trained in all aspects related to the task(s)
to be performed?

Additional Control Methods

required to be in place during course of the work)

Attendees During Detailed Risk Assessments

Certification that this permit has been reviewed and the work can be completed safely.

Printed Name Signature

Electrically
Qualified
Persons

participant

participant

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 Safety: Electrical Work Permit

participant

participant

participant

ES Department Rep: Date:

Electrical Work Review:
Proposed Electrical Work
has been reviewed and
approved by: Resident Engineer/Engineering manager: Date:

Supervisor Date:

A copy of the completed permit must be kept available for review at the work location.
The permit is valid for one (1) shift
(SOP and OPL must be in place to extend permit beyond 1 shift for NFPA 130.2(B)(1))

PERMIT CLEARANCE/CANCELLATION

All work has been completed / cancelled and the personnel and equipment have been withdrawn
from the area identified in the permit. The work area has been cleaned, inspected and the area is
ready for normal use / all hazards are removed or controlled. (circle one)
This permit is hereby cancelled.
Name of ABI Representative: Date:

Upon completion of work, the AB Person responsible for the work must retain the completed
Energized Electrical Work Permit for 30 days.

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 Safety: Electrical Work Permit

The Section Below Applies Only To Contractor Work

(For work by ABI employees, the fourth page is not required)

CONTRACTOR LAST CHECK YE

N/A
S

 This Contractor Last Check must be completed for all work conducted on
equipment/processes with potential Exposure to Hazardous Substances by contractor
employees.
 A Last Check must be performed by both the Contractor Safety Supervisor &
the responsible ABI Person.
 The purpose of the Last Check is to verify the Risk Assessment was properly
completed and that the work area was reviewed. Any “NO” Answers Prohibit Work and
Requires that Additional Control Methods be Implemented.

 Is the housekeeping of the area where the contractor needs to work

maintained?
The area is in good condition and free of any recognized (uncontrolled) hazards.

 Is area where the contractor needs to work readily accessible?

 Is the proper signage in place to indicate where the contractor is working?

 Has the required risk assessment been completed?

 Are the ABI employees that are working in the same area made aware of the work
done by the contractor?

 In case several (sub) contractors work at the same time in the same area:
Is there a proper coordination between the concerned parties so that everybody is aware
of each others’ activities & hazards?

 Have the necessary work permits been completed?

 Are all means available to perform a proper lock-out tag-out?

 Is all the necessary personal protective equipment available?

 Are possible emergencies that can occur in the workplace identified?

Attach to associated work

permit and retain

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 Safety: Electrical Work Permit

Name of ABI Responsible

Person

Name of Contractor Safety

Date
Supervisor (Print)

Signature Of Contractor
Safety Supervisor

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