LIMITATION OF ACCESS

WORK PERMIT No: SERIAL No:

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

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

Permission is given to carry out the following Work on the Electrical Equipment detailed below which is in the
vicinity of Live exposed conductors. The Work shall be carried out in accordance with AFPC Electrical Safety
Rules.

EQUIPMENT: .....................................................................................................................................................
WORK TO BE DONE: ......................................................................................................................................
...........................................................................................................................................................................

NO OTHER WORK SHALL BE CARRIED OUT!

LIVE ELECTRICAL EQUIPMENT: ...................................................................................................................

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SPECIAL PRECAUTIONS TAKEN: ......................................................................................................................
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PRECAUTIONS REQUIRED: ................................................................................................................................
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KEY SAFES/SAFETY LOCK NOS: ....................................................................................................................

DATE: ....................................................................... TIME:.................................................................................

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

2. RECEIPT
I have checked the precautions taken and conformed with the precautions required and accept responsibility for
carrying out the work detailed on this Limitation of Access. No other work will be done by me or any person
under my charge.

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 carry out the work
detailed in this Limitation of Access.

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

4. CANCELLATION
This Limitation of Access is cancelled.

DATE:..........................................................................TIME:.................................................................................
NAME :........................................................................SIGNATURE.....................................................................
(IN BLOCKLETTERS) (SAEP)

* Delete whatever is not applicable REV C:- Jan 2001 MESC 93-55-81-028-9
White Copy- Permit Holder, Pink Copy – Senior Authorised Electrical Person , Blue Copy- Retained by Permit Co-ordinator
 LIMITATION OF ACCESS
5. CROSS REFERENCES:....................................../................................................/............................................

* Delete whatever is not applicable REV C:- Jan 2001 MESC 93-55-81-028-9
White Copy- Permit Holder, Pink Copy – Senior Authorised Electrical Person , Blue Copy- Retained by Permit Co-ordinator