Date

GENERAL WORK PERMIT JSA No. Vendor LOGO

A. REQUEST TEAM
1 Name of the Contractor -

2 Area & Location -

3 Date and time of work start -

4 Date and time of work finish -

5 Permit Extension details -

6 Tools and Equipment’s involved -
7 Description of Works

Contractor Execution Engineer Contractor HSE officer

Name and Signature Name and Signature

Date & Time Date & Time

PERSONEL PROTECTIVE EQUIPMENTS C MANDITORY SAFETY PRECAUTIONS (Please Tick)

B. TO BE USED (Tick as required) Safe access, egress made available all floors/elevators
1 Yes NA

1. Safety Shoe YES NA 2 Safety induction Training and project ID card for involved workers Yes NA

2. Safety Helmet YES NA Job Specific Training briefed prior start up any new activity Yes NA
3
Reflective Jacket YES NA 4 Yes NA
3. Activity carried out with Method Statement & JSA

4. Hand Gloves YES NA 5 Safety Signage boards provided appropriately Yes NA

YES NA Body earth for all applicable equipment’s is provided. Yes NA

6. Ear Protection 6
YES NA Area cordon off for excavation, lifting equipment operation Yes NA
7. Eye Protection 8
YES NA Yes NA
8. Job Specific PPE’s as per job nature Vehicles, machinery, Lifting tool be inspected prior to use
9
Suggest job specific PPE’s - All floor opening, Floor edge and Shaft are protected
10.
Remarks – (Safety violation / Deviation at Work Place while work execution / Permit review)
D - Additional Safety Precautions for Works
(Can be Suggested by Client/PMC/Vendor)

E – PERMIT APPROVAL BY PMC F 1.1 - PERMIT CLOSING DETAILS

Sign Sign Sign

Sign Sign
Time Time Time
Time Time

PMC Site Engineer PMC – HSE Site Eng. S/C HSE – S/C PMC - HSE
F – 1.2 PERMIT CLOSE CONDITION

1. Housekeeping of the work place is maintained.

2. All the tools, tackles are secured.
3. Material stacked properly and sign board displayed.
4. Vehicle, machinery parked with stopper and locked.
5. Floor openings, guard rails, shafts are protected.

PTWS – General Work Permit - R1 – 10.03.2017 Page 1 of 1