ENVIRONMENTAL, HEALTH, SAFETY & SECURITY

Document Type: Form Document No.: EHSS-PERMIT-001 Revision No.: 00

WORK PERMIT
PROJECT: PERMIT NO:

COMPANY : NAME OF SUPERVISOR :

START DATE and TIME : EXPECTED FINISHED DATE and TIME:

WORK LOCATION : VALIDITY DATE :

DESCRIPTION OF WORK/S:

LIST OF PERSON/S WHO WILL PERFORM THE TASKS : (PLEASE USE ANOTHER SHEET IF MORE THAN 10)
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
SAFETY REQUIREMENTS :( LIST ALL SAFETY REQUIREMENTS TO BE ABLE TO PERFORM THE TASK SAFELY. USE ANOTHER SHEET IF MORE THAN 6)
1. 4.
2. 5
3 6
OTHER PERMITS REQUIRED: (Check all that applies. Approved copies should be attached to this form)
( ) HOT WORK ( ) CONFINED SPACE PERMIT ( ) SCAFFOLDING ( ) EXCAVATION / TRENCHING
( ) INSTALLATION ( ) CRITICAL LIFTING ( ) LOCKOUT / TAG-OUT
( ) STRIPPING ( ) OTHERS (please specify:____________________)
OTHER REQUIREMENTS: (Check all that applies. Answer YES if complied or completed already)
( ) DRAWINGS, COMPLETED? ______
( ) NECESSARY SUPPORTING ATTACHMENTS AND PERMITS, COMPLETED? ______
( ) WORK AREA SAFETY PLAN, COMPLETED? ______
( ) OTHERS, PLEASE SPECIFY:

PREPARED BY:
NAME DESIGNATION DATE AND TIME

CHECKED BY:

MHI ENGINEER/SUPERVISOR SUBCON OPERATIONS / SAFETY OFFICER

DATE: DATE:

VERIFIED BY: REVIEWED BY: APPROVED BY:

PROJECT-IN-CHARGE SAFETY OFFICER PROJECT MANAGER

DATE: DATE: DATE:

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