PERMIT TO WORK

Section

Serial No

Plant Area

Work Order No
Key Safe No

I hereby declare that the following is Dead/ Isolated from all live conductors, earthed and short circuited, and is
safe to be worked upon, ALL OTHER PARTS OF THE SYSTEM ARE TO BE TREATED AS DANGEROUS,
AND ALL TNB REMACO SAFETY RULES ARE TO BE OBSERVED.
(a) Circuit Designation

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...........................
...........................

(b) Here describe EXACTLY

the only Apparatus on
which work is to be done

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...............................
...........................

(c) Here describe EXACTLY

at what points the
Apparatus has been earthed
And short circuited.
(Circuit Main Earths)

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..........................
..........................
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Note: -These CIRCUIT MAIN EARTHS may not be altered except by or on the instructions of the Authorised
Person whose signature appears below.

(d) Here describe the nature

of the work to be done

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............................

Issued by :.......................................................................................*a person duly authorised in accordance TNBRP Safety Rules

Signature :..
Date

: ....

Time

: ..

* Name of Authorised Person signing the Certificate to be written here in block letters

Note 1 - This Certificate after being signed by the Authorised Person is to be handed to the Competent Person in
charge of the work, and retained by him or his "relief" until the work is completed or stopped by the Authorised
Person. A "relief" may only take charge with the approval of the Authorised Person who must take reasonable steps
to ensure that the "relief" understands clearly the precise extent of the work permitted by this Certificate. All
Competent Person to whom this Certificate is issued must sign the following receipt form:
Received by :

Name

Staff No.

Signature

Date

Time

First Competent Person

.....

...

.......

. .

Second Competent Person

.....

...

.......

. .

Third Competent Person

.....

...

.......

. ..

Note 2 - The apparatus mentioned hereon must not again be made alive until the declaration below has been signed
by the Competent Person last in charge of the work and the Certificate has been returned to the Authorised Person
whose name appears on the face of this Certificate. The Authorised Person must cancel the Certificate before he
attempts to make alive again.

CLEARANCE CERTIFICATE
I hereby declare that all additional earths connected by me have now been removed, and all men under my charge
have been warned that it is no longer safe to work on the apparatus specified in this Certificate.

Signature.........................................
(Competent Person)
Name..
Date : .

Time: .

CANCELLATION
Note 3 - When the above declaration has been signed, and the Certificate returned to the Authorised
Person, the Authorised Person must sign the declaration below and also write
CANCELLED across the face of the original and all copies and thus cancel the permit.
I hereby certify that this Permit to Work Certificate is cancelled.

Signature: ..............................................................
Name

: .....

Date & Time

: .