Integrated Management System

HSE-F-18 Rev-00 /Issue-01 15/04/2019

PERMIT TO WORK AT HEIGHT

DATE OF ISSUE TIME OF ISSUE Ref No:

PROJECT NAME: PROJECT NO:

WORKING AREA LOCATION:
WORK DESCRIPTION
SL NO DESCRIPTION N/A NO YES
01 Personnel fall arrest system (Full body harness) is provided?
02 Instruction given for the proper use of safety harness
03 Provide adequate access and platforms
04 Scaffolding are properly made for job as per municipality standard
Scaffolding tag which is duly signed by municipality 3rd party approved scaffolding supervisor is
05
on the scaffolding
06 Is the working area well protected from falling or collapse?
07 Municipality 3rd party approved Scaffolding erectors are available for scaffolding erection
08 Tool box talk conducted for work at height
09 HSE induction training conducted all workers
10 All lifting Equipment’s/ hydraulic equipment’s possess municipality 3rd party approved
11 Adequate Edge protection is Provided
12 Safe angle provides for ladders
13 Banks men available for controlling vehicle/ equipment’s movements
14 8 to 10 mm wire rope (Lifeline) available for work at height
Height work at for the purpose:

PERMIT ISSUER (Project In charge/ Assigned Representative):

I have issued the permit after evaluating the above checklist and remarks to carry out the job in the area described, within the time
indicated
Name of the Company: Name Signature

PERMIT HOLDER (Worker/ Supervisor)

I have checked both the permit and the job. I understand the nature and extent of the work and the precautions to be followed in
completing the job and I agree to comply with all the safety precautions.
Name of the Company: Name Signature

HSE Dept COMMENTS:

APPROVED BY HSE DEPARTMENT

I have checked the location, Scaffolding tag displayed and all necessary precautions as stated above are taken
Name Job Title Signature

CLOSURE OF PERMIT (HSE DEPARTMENT:

The Height work s are now completed. Work area and adjacent area are safe
Work Complete at date & Time HSE Incharge Signature