HEALTH, SAFETY & ENVIRONMENT PLAN

Lifting and Shifting Work Permit

(For Heavy Equipment’s & Objects)

Permit No. : Date :

Project : Emergency Contact No. :
Location :
Job Description :
Contractor :

Name of the Equipment / Associated Equipment: Equipment Code number(s):

List of Tools & Tackles to be used for Name(s) of workmen Documents attached:
the work: involved: 1. Test Certificates- 2. Lift Plan-
3. Load Chart- 4. JSA/HIRA-

S. CHECKLIST DESCRIPTION Yes / No

Remarks
No /NA
Is the lifting zone cordoned off adequately, to prevent access by
1 unauthorized personnel?

Is appropriate caution sign board prominently displayed at the site of

2
operation?
3 Is the area clear of over-head electrical lines?

4 Third party inspection certificates available for all tools & equipment’s.

The system to be isolated and proved dead as per LOTO procedure (Tick √
applicable)
5
Electrical Mechanical Specify any other Energy presence

Is the Safe Work Load marked on the equipment?

6 Name of Equipment: __________ SWL: __________________

7 Are the PUC Certificate and Vehicle Fitness Certificate from RTO, available?

Has the lifting equipment been examined at least once in the last 12
months by an authorized examiner (third party) and does it possess valid
8
lifting equipment certificate

Is the driver competent to handle the equipment? Does he have the license
9 for Heavy Transport Vehicle?

Has the actual weight of the load been handled, established and within the
10 Safe Work Load of the equipment? Wt. of load: ______
Is the hook of the equipment in good condition and has been provided with
11
a locking latch?
12 Is the Load Test Certificate of the hook available?

Is the load likely to clash with other structures or equipment along its
13
lifting path?

14 Is a tag line provided to control movement of the load?

 HEALTH, SAFETY & ENVIRONMENT PLAN

Has a safe means of access or egress been provided for personnel to

15
attach or recover the rigging of the load?
Has the area been surveyed to identify the presence of potential
16
hazards?

17 Soil is compacted and suitable for movement of Cranes

18 Are all workers wearing required PPE?

19 Is personal movement below the suspended loads restricted?

20 Cranes / Lifting Equipment are in perfect position on firm ground?

21 Is authorized signal man available for signaling?

22 Supervisor present at the job site till the time the job is completed?

Any other points to be checked:

23

A. Permit Initiation & Issue

Declaration of initiator / Contractor:

a. All the above safety precautions have been put in place, based on Job safety analysis as per
method statement and verified by me on ground personally.
b. I shall ensure all the necessary precautions, till end of the work & I shall take full responsibility in
case of any deviations or lapses noticed on site.

Permit Initiator
(Contractor PM / Engineer & safety)

Comments by M Moser (if any)

Permit is issued based on work progress schedule & on the above declaration from the contractor. In case of any
NC noticed by M Moser/ consultant/client during site rounds, necessary actions as per Contract/Statutory
conditions shall be taken.

The safety precautions and safe conditions mentioned above have been verified and work can be started.
Permit is granted & valid up to date ………………………………& time: from………………. to ………………………..

M Moser Project Team

B. Permit Closure:

The above-mentioned job has been completed satisfactorily. Date…………………………………. & Time ……………………………… this
permit is closed.

Permit Initiator
(Contractor PM / Engineer & Safety)

Comments by M Moser (if any)

MMoser Project Team

 HEALTH, SAFETY & ENVIRONMENT PLAN

DATE PERMIT INITIATOR CONTRACTOR MMOSER PROJECT TEAM REMARKS

SIGNATURE SAFETY SIGNATURE