Doc. No.

FO-VTC-HSE-001
Valmet Technology Center
Rev. 00 Date: 15 June 2020
SAFE WORK PERMIT

Page 01 of 03

Name of Contractor company

Contact name and number of site supervisor
Scope of Work
Duration of work
Intended start day and time of work
Area / Location of work
Number of workers including subcontractors

Contact name and number of Valmet work

supervisor

All workers must complete site induction (tick below to confirm understanding)
Emergency evacuation Hazard near miss Incident reporting
Site specific hazards / risk controls Traffic management controls

Personal Protective Equipment (PPE): You must provide the required PPE.
Minimum requirement: Safety glasses, safety shoes, appropriate workwear and high viz vest or shirt.
Gloves Welding mask Face mask Safety harness/Lanyard
Dust mask Hard hat Others (Spill kits?)

Tools & Equipment (PPE): All equipment & Tool must be appropriate for the task, safe
and inspected.
Minimum requirement: Check Tools / equipment before use
Name of Date of Inspection condition Other
tools/equipment

Specific high risk permits requirement (Circle relevant one and ensure compliance to
controls noted)
Hot Work (Grinding
and welding activities)

Elevated work (any

work above ground)
 Doc. No. FO-VTC-HSE-001
Valmet Technology Center
Rev. 00 Date: 15 June 2020
SAFE WORK PERMIT

Page 02 of 03

Documentation requirement
Job Safety
Environment
Analysis (JSEA)

Training /
Competency
tickets

Any general / specific comments

Note:
1. This permit can ONLY be issued by a Valmet work supervisor.
2. The contractor supervisor must complete this form and submit to the Valmet work supervisor to issue it.
3. If the duration of work is longer than a day or shift, then the contractors must report to the work supervisor or
his/her delegate every day prior to accessing site for work.
4. All contractors must sign in and out of work every day.
5. If the scope of work changes, a new permit to work will be required.
6. Valmet reserves the right to escort the contractors off site if there are significant safety breaches or repetitive
safety non-compliance.
7. It is the responsibility of the contractor supervisor to ensure that their employees and subcontractors are
competent in the tasks they are assigned to, and have had all relevant safety training and awareness.
8. It is the responsibility of the contractor supervisor to ensure your employees or subcontractors comply with all
safety rules on site, and any safety requirement documented in this permit and/or the JSEA.
9. It is the responsibility of the contractor supervisor to ensure that your employees and subcontractors understand
the requirement of site and JSEA.
10. The completed permit to work along with the JSEA must be kept at the job site during work and returned to work
supervisor at completion of the task.
 Doc. No. FO-VTC-HSE-001
Valmet Technology Center
Rev. 00 Date: 15 June 2020
SAFE WORK PERMIT

Page 03 of 03

11. Acknowledgements and Signature

Do not start work until this section has been completed.

Permit issuer (Valmet work supervisor)

Name
Signature
Date

Permit Acceptor (Contractor supervisor)

Name
Signature
Date

Completion of work (Contractor supervisor and Valmet supervisor to confirm/sign)

Work has been completed efficiently / safely. Tools put away and area cleaned
Area revised and confirmed all ok.
Date / Time