TG

Module : Permit to work Exported from CUBE by Kaushlendra Kumar on Jul 19,2024 at 10:23:11 AM

MP Metro

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33kV CKT-02 Shutdown required

Form No 4142 Name
from GN Station to G

Form Template
IN - PTW With Power Block PTW & PWC
Template Type

Raised By Santosh Raised on Jul 19,2024 at 10:01:11 AM

33kV Cable clamping and

Description Status In progress
dressing near Ramp area.

PART A: APPLICANT (EPIC)

I (Name of the EPIC)

*
Name : Santosh

Contact : null

Designation : null

Org : KPTL

Emp No

* 22087

Department

* PST

Contractor
* KPTL

Along with below no. of contractor staff

* 4

Along with below no. of GC Staff

1

Along with below no. of MPMRCL Staff,

1

Request for Permit to Work in Controlled Area From

* Gandhi Nagar Station Up Line

Remarks (Please Specify the controlled area From in case of 'Other')

Request for Permit to Work in Controlled Area To

* Depot Ramp P-1020

Remarks (Please Specify the controlled area To in case of 'Other')

For the purpose of

* 33kV Cable dressing and punch points

attending.

From Date & Time

* Jul 19,2024 at 10:02:07 AM

To Date & Time

* Jul 19,2024 at 05:00:00 PM

Power Block is Required

* Yes
 Entry Point

* Gandhi Nagar Station Up Line

Remarks (Please Specify the Entry Point in case of 'Other')

Exit Point

* Depot Ramp P-1020

Remarks (Please Specify the Exit Point in case of 'Other')

Check All staff including myself having PPE.

* Yes

Check for strictly following all safety precautions with respect to HOT Work, Work at Height etc.

* Yes

Name, Contact No. & Signature

*
Name : Santosh

Contact : null

Designation : null

Emergency Contact Person Name

Santhosh

Emergency Contact Person Number

7000377004

PART B: ACKNOWLEDGE BY PC

It is confirmed that General Work plan is complied

* Yes
 Why are you raising a PTW if General Work Plan is not complied?
instructions : If YES, Please fill NA
*
NA

Name

*
Name : Kaushlendra Kumar

Contact : 919123479421

Designation : Sr. T&C Expert

PART C: DE-ENERGISATION BY TPC

It is confirmed that the above requested section has/have been de-energized and SCD(s)
has/have been applied. The section is safe to work.
*
Yes

Name

*
Name : Sundeep Suman

Contact : 918249715090

Designation : Engineer

PART D: REVIEW OF APPLICATION AND APPROVAL BY PC

The request for the above work (as mentioned in Part A) is Approved / Not Approved.

* Approved

Remarks
Ensure work place must be clear from obstruction after completion of the work,
Ensure no damage of third rail and other rail asset, Ensure safety of
men/material during work, list of men power is with EPIC. Keep clear distance
from 33 KV charged cable on mainline. Hot welding not allowed on this permit.

Name

*
Name : Kaushlendra Kumar

Contact : 919123479421
 Designation : Sr. T&C Expert

PART E: CANCEL REQUEST (EPIC)

I (Name of the EPIC)

Emp No

Department

Contractor

Hereby request to cancel the Work Permit No. issued to me. :

Is the time of cancellation later than the time approved in PTW.

If Yes, do you have an approved PTW Extension form Number

instructions : Leave blank if PTW is not burst

Please fill the approved PTW extension form number

instructions : Leave blank if you do not have PTW Extension form Number

1. Further, I hereby certify that, All Men and Material have been taken out of the section

2. There are NO infringements caused to the structural gauge / moving dimensions.

 *

3. Work trolleys / Vehicles other than Rolling Stock has been parked / stabled at designated
locations, brakes applied and secured.
*

4. All work in the vicinity of third rail / power lines / equipment have been completed and it is
safe to charge. Request to cancel the availed Power Block.
*

5a. The traction fitness certificate issued pertaining to the section where the work has been
permitted vide above mentioned PTW No. remains valid, and NO change in fitness is declared.
*

5b. The traction fitness certificate issued on

instructions : If 5a is NA, Please leave this blank.

6a. The track fitness certificate issued pertaining to the section where the work has been
permitted vide above mentioned PTW No. remains valid, and NO change in fitness is declared.
*

6b. The track fitness certificate issued on

instructions : If 6a is NA, Please leave this blank.

7. All S&T gears / Installations are fit for movement of traffic.

Name of EPIC

PART F : ACKNOWLEDGEMENT BY GC

The request for Cancellation of the above work (as mentioned in Part A) is Acknowledged.

Name

PART G : CANCELLATION APPROVAL BY PC

 The request for Cancellation of the above work (as mentioned in Part A) is

Name

PART A: APPLICANT (EPIC)

PART A: APPLICANT (EPIC) Submission on Jul 19,2024 at 10:02:43 AM by Santosh

PART B: ACKNOWLEDGE BY PC
PART B: ACKNOWLEDGE BY PC Submission on Jul 19,2024 at 10:10:03 AM by Kaushlendra
Kumar

PART C: DE-ENERGISATION BY TPC

PART C: DE-ENERGISATION BY TPC Submission on Jul 19,2024 at 10:11:37 AM by Sundeep
Suman

PART D: REVIEW OF APPLICATION AND APPROVAL BY PC

PART D: REVIEW OF APPLICATION AND APPROVAL BY PC Submission on Jul 19,2024 at
10:12:55 AM by Kaushlendra Kumar

PART E: CANCEL REQUEST (EPIC)

In-Progress

PART F : ACKNOWLEDGEMENT BY GC
Waiting

PART G : CANCELLATION APPROVAL BY PC

Waiting

PART H : CLOSURE
Waiting