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Date Prepared: Permit No.:

CONFINED SPACE ENTRY PERMIT

Permit to Work Activity:

Task specific, Work Procedure, Method Statement / Risk Assessment (MSRA) Attached:

SECTION 1: WORK REQUEST BY CONTRACTOR

PTW Applicant / Requester name BLOCK LETTERS Date: Time: Signature

Phone Number
Permit ID Number
Radio Frez:

Detailed Work Location/KKS:

SECTION 2: ACTIVITY SPECIFIC DETAILS AND TYPE OF WORK TO BE PERFORMED – ADDITIONAL HSE MEASURES

SECTION 3: HAZARDS

Oxygen (Less than Flammable Gases or Toxic Gases or Vapors

Hot Work 19.5% or Greater than Vapors (Greater than 1% of (Greater than PEL /
23.5%) LEL) TLV)

Work at Height / Contact with Hazardous High Temperatures (Hot Mechanical / Electrical
Scaffolding Materials Surfaces / Heat Stress) Hazard

Nitrogen Other Hazards: MS / RA Required

Gas Test Requirements Gas Test Frequency:

SECTION 4: PPE REQUIRED

Face Shield Boots Gloves Goggles

Chemical Resistant /
Air Line Dust Mask Chemical / Dust Respirator
Acid Suit

SCBA Full Encapsulated Suit Other:

SECTION 5: ISOLATION and PREPARATION for ENTRY COMPLETE

PEFS attached Lines Blinded / Broke Lock Out / Tag Out Purged / Cleaned

Lights (Low Voltage with

Inert Complete Ventilation in Place Access Good
GFCI / Handheld)

Hot Work Scaffold Approved Barriers / Warning Signs Other:

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SECTION 6: EMERGENCY

Requires Full Body

Rescue Plan Attached Requires Mechanical Hoist / Life Line
Harness

Method of Communication between Hole Watch and

Method of Communication to Emergency Rescue Team
Entrants

SECTION 7: APPROVALS

Name Block Letters Date Time Signature

MCS Senior Authorize (C/M/E)

IP Site Manager

MSC HSE Manager

MSC Site Manager

Permit Coordinator

Permit Start (Time / Date):

Permit Finish Date & Time:
NWOTE: Valid for 7 days only

SECTION 8: PTW ACCEPTED BY CONTRACTOR

Name Block Letters Date Time Signature

PTW Holder (Foreman)

Contractor Authorized Engineer

Contractor Site Manager

Consortiumn Area HSE

Number of craft working on the PTW

TI Reference:

SECTION 9: PTW CLOSED

Name Block Letters Date Time Signature

PTW holder (Foreman)

Consortiumn Area HSE

PTW Coordinator
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*For works interfering with existing power plant only (demolition, operational areas, operational system)