ELECTRICAL PERMIT TO WORK

WORK PERMIT No: SERIAL No:

1. ISSUE LOCATION...............................................

To:.......................................................................(SAEP/AEP/CEP) *

The following Electrical Equipment has been made safe in accordance with the AFPC Electrical Safety Rules for
the work detailed in 1a below:
.................................................................................................................................................................................
.................................................................................................................................................................................
TREAT ALL OTHER ELECTRICAL EQUIPMENT AS LIVE!
1a. WORKSCOPE
Work to be completed:.............................................................................................................................................
.................................................................................................................................................................................
................................................................................................................................................................................
1b. ELECTRICAL PRECAUTIONS TAKEN.

POINTS AT WHICH THE ELECTRICAL EQUIPMENT HAS BEEN ISOLATED AND CAUTION
NOTICES ATTACHED:........................................................................................................................................
.................................................................................................................................................................................
DANGER NOTICES ATTACHED
AT:..................................................................................................................
CIRCUIT MAIN EARTH APPLIED AT:..............................................................................................................
NUMBERS OF ADDITIONAL EARTHS ISSUED:...............................................................................................
KEY SAFES/SAFETY LOCK NOS:......................................................................................................................
OTHER PRECAUTIONS:........................................................................................................................................

DATE:..........................................................................TIME:.................................................................................
NAME :........................................................................SIGNATURE.....................................................................
(IN BLOCK LETTERS) (SAEP)

2. RECEIPT
I have checked the precautions taken and accept responsibility for carrying out the work on the Electrical
Equipment detailed on this Electrical Permit to Work and no attempt will be made by me or persons under my
charge to work on any other Electrical Equipment.

DATE:..........................................................................TIME:.................................................................................
NAME :........................................................................SIGNATURE.....................................................................
(IN BLOCK LETTERS) (SAEP/AEP/CEP )*

3. HAND BACK OF WORK

All persons under my charge have now been withdrawn and warned that it is no longer safe to work on the
Electrical Equipment detailed on this Electrical Permit to Work. All tools, equipment and Additional Earths
have been removed.
The work is Complete/Incomplete*

DATE:..........................................................................TIME:.................................................................................
NAME :........................................................................SIGNATURE.....................................................................
(IN BLOCK LETTERS) (SAEP/AEP/CEP)*

4. CANCELLATION
All Earths specified in Part 1 have been removed and this Electrical Permit to Work is cancelled.

DATE:..........................................................................TIME:.................................................................................
* Delete whatever is not applicable REV C:- Jan 2001 MESC 93-55-81-012-9
White Copy- Permit Holder, Pink Copy – Senior Authorised Electrical Person , Blue Copy- Retained by Permit Co-ordinator
 ELECTRICAL PERMIT TO WORK
NAME :........................................................................SIGNATURE.....................................................................
(IN BLOCK LETTERS) (SAEP)

5. CROSS REFERENCES:....................................../................................................/............................................

* Delete whatever is not applicable REV C:- Jan 2001 MESC 93-55-81-012-9
White Copy- Permit Holder, Pink Copy – Senior Authorised Electrical Person , Blue Copy- Retained by Permit Co-ordinator