Doc No.

AP/SFT/106/WPS/CSE

ADVENT PROJECTS & CONSULTANCY SERVICES PVT. LTD. Rev 01

CONFINED SPACE ENTRY PERMIT
Date & Time- Permit no-

Project Name-
Name of Sub Contractor-
Area & Location-
Date & Time of Work Start-
Date & Time of Work Finish-
Tools and Equipment involved-
Job Description-

Note: In case of any hot work, excavation works, working at height or at confined space
entry ensure relevant work permit has been issued.

Details Sub-Contractor Area in-charge/Engineer

Name
Signature
Date
This permit does not relieve user from responsibility with
respect to safety precautions, user must fully understand the
NOTE
site conditions, validity of permit, personally checked by permit
issuer and user.

ATMOSPHERIC TESTING
Testing Unit calibrated within last one year? Yes/No
Battery checked? Yes/No
Location %O2 %LEL Toxic gas (e.g.,
hydrogen sulphide)
Prior to entry
At opening
Middle
Bottom
Below 10 % of Below TLV (see
Acceptable limits 19 - 23.5% LEL MSDS)

SAFETY CHECKLIST BEFORE COMMENCEMENT OF WORK YES/NO/NA

1 All sources of electricity, utility isolated and tagged "Do Not Operate"

2 Space cleaned and Free of Contaminants

3 Establish continuous ventilation/monitoring if required.

4 Communication checked between entrants and attendant (List how)

5 24 V lighting available, if needed

6 Lockout/tag out completed (if needed)

7 Appropriate PPE worn

Advent Projects and Consultancy services Pvt. Ltd. Pune|India

 Doc No. AP/SFT/106/WPS/CSE

ADVENT PROJECTS & CONSULTANCY SERVICES PVT. LTD. Rev 01

CONFINED SPACE ENTRY PERMIT
8 Appropriate Tools available

9 Heat conditions assessed Temperature:

10 Others (list)

PPE’s & Other YES/No/NA PPE’s & Other Requirements YES/NO/NA

Requirements
Helmet Safety Net:
Safety Belt: Barricade the construction site:
Ear Muffs / Ear Plugs: Scaffolding required
Hand Gloves– Safety Guide rope required
Safety Goggles Fire extinguishers:
Safety Shoes Lockout and Tag out :
Breathing apparatus Masks:

Highlighted jackets Others

Remarks /additional safety measures required if any:-

COUNTER SIGNATURES
I have received a copy of this permit and have understood it. I undertake to follow all the
precautions specified. (VENDOR TEAM)

Name of Project Safety Engineer:___________________________Signature:________________

Name of Project Manager/Engineer:_________________________Signature:_________________

APPROVED BY APCSPL TEAM:

Name of the Project Engineer : ____________________________Signature: _________________

Name of Safety In charge: _______________________________Signature:_________________

RENEWAL & PERMIT BEYOND STIPULATED TIME:
Remarks if any-

Permit extended up to date & Time: ________________

Name of Safety In charge:________________________________Signature:__________________

The job has been completed and inspected by safety department. All workmen have been

withdrawn; tools removed and job left tidy.

Remarks if any__________________________________________________________________

Date & Time __Name: __________Signature:

Advent Projects and Consultancy services Pvt. Ltd. Pune|India