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1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA (Not Applicable) Valid for a shift-After This permit Renewal Required
Description of work
2 Hazards Identified
Confined Space Tripping Hazard Excavation Collapse High Voltage Heavy Lifts Hazardous Substances
High pressure jet Pressurised Pipework Electrocution Fall from Height Steam Pressurised Hose Failure
Slipping Hazards Ackward Access Flammable Material Hydrocarbon Area Noise Chemical Hazard
Inadequate Lighting Dropped Objects Radioactive Source Static Electricity Vibration Drowning
3 Controls in Place
A Initial Gas Testing Oxygen Content Check Continuous Gas Test Fire /Safety Watcher Portable Fire Extinguishers
MSDS Precautions Additional Lighting Hose Whip Check Lifting plan/Equipment Intrisically Safe Equipment
Simultaneous opn identified and Risk accessment done Equipment Earthing & Bonding Flammables Removed Radioactivity Controls in Place
B Additional PPEs Standards - Helmets, Safety Shoes and Safety Goggles are mandatory
Leather Gloves Electrical Gloves Cotton Gloves PVC Gloves Heat Resistant Gloves
Maintenance Gloves Aluminium Suit Chemical Splash sheild Leg Guard Face Shield
Dust Mask/SCBA Arc Flash Suit Safety Harness Steam resistant gloves & Suit Tool Box Meeting
C Job safety Analysis HIRADeC are mandatory for all work associated with safety Systems HIRADeC & SWP/WI/SOP/SMP No:
D Additional Controls
Note : Sl No 1 to 3 Needs to be filled one day in advance from the Actual Work Execution Day and Annexures to be added if space is less anywhere
4 Isolation Required
Isolation Certificate Cert No. Confined Space Certificate Cert No. Excavation Certificate Cert No.
Height Work Certificate Cert No. High Voltage Switching certificate Cert No.
Note : The Above Authorization is required for Identified Critical Jobs & for unplanned Emergency Jobs to be started on the same day
6 Issue
I the Shift Incharge / Area Authority ,declare that all hazards have been identified and all control measures are
in place and it is now safe for the work specified on this permit to be performed and is valid. I the Field Engineer/Operator confirms that all hazards identified and all control measures specified are in
From : To : place and it is now safe to carry out the work specified on this permit.
hrs hrs From : hrs To : hrs
Name Signature Designation Date Time Name Signature Designation Date Time
I the Performing Authority, have read and understood the above conditions and precautions. I accept responsibility for carrying out the work as specified.I will ensure the persons under my control read,understand and comply
with these conditions and precautions.I will notify the Operation Shift Incharge / Area Authority on completion or interruption of this work.
7 Permit Renewal
Date:
From:
To:
Performing Authority
8 Permit Sign of
Performing Authority: I declare that all persons have been withdrawn and that all tools,plant and equipment
used have been removed and the site left in a safe clean and tidy condition.
Shift In Charge ( Issuer ) I declare the work task is :- Complete Incomplete Isolations/Overrides can be removed:
1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA (Not Applicable) Valid for a shift-After This permit Renewal Required
Description of work
Name of Persons Working
Note : ( Separate sheet to be attached in case of insufficient space above or change of persons during work)
Name of the working Agency
Tools & Equipments
2 Hazards Identified
Confined Space Tripping Hazard Excavation Collapse Toxic Gas Fumes Heavy Lifts Hazardous Substances
Mechanical/Electrica
l Sparks Hot surface Moving Machinery Fall from Height Steam Unguarded Opening
Slipping Hazards Ackward Access Flammable Material Hydrocarbon Area Noise Pressurised Pipework
Inadequate Lighting Dropped Objects Radioactive Source Static Electricity Vibration Pressurised Hose Failure
3 Controls in Place
A Initial Gas Testing Oxygen Content Check Hose whip Check Continuous Gas Test Fire /Safety Watcher Portable Fire Extinguishers
Signs & Barriers Welding MC Checklist Gas Cutting Checklist Venting Fire Blanket/Screen Drains flushed & covered
Charged Fire Hose Additional Lighting Ear Protection Safe Access/Egress Lifting plan/Equipment MSDS Precautions
De-Pressurised Draining Secure Loose Objects Purging Extinguisher/Fire Tender Manual Handling equipment
Equipment Earthing
Simultaneous opn identified and Risk assessment carried out Caps on Gas Cylinders Flammables Removed Emergency preparedness
& Bonding
Flash Back Arrestor Gas Cylinder with trolley Intrintisically Safe Equipment Welder Apron
B Additional PPEs Standards - Helmets, Safety Shoes and Safety Goggles are mandatory
Leather Gloves Electrical Gloves Cotton Gloves PVC Gloves Heat Resistant Gloves
Maintenance Gloves Aluminium Suit Chemical Splash sheild Leg Guard Face Shield
Dust Mask/SCBA Arc Flash Suit Safety Harness Steam resistant gloves & Suit Tool Box Meeting
C Job safety Analysis HIRADeC are mandatory for all work associated with safety Systems HIRADeC & SWP/WI/SOP/SMP No:
D Additional Controls
Note : Sl No 1 to 3 Needs to be filled one day in advance from the Actual Work Execution Day and Annexures to be added if space is less anywhere
4 Isolation Required
Isolation Certificate Cert No. Confined Space Certificate Cert No. Excavation Certificate Cert No.
Height Work Certificate Cert No. High Voltage Switching certificate Cert No.
Note : The Above Authorization is required for Identified Critical Jobs & for unplanned Emergency Jobs to be started on the same day
6 Site Atmosphere Test : (Mandatory for Critical Areas other than Confined Space`where possibility of Hydrocarbon or other gases is existant)
Initial Test by Authorised Gas Tester ;Continuous Monitoring by Performing Authority /Safety Watch
Date Time LEL O2 Toxic CO Other Signature Date Time LEL O2 Toxic CO Other Signature
7 Issue
I the Shift Incharge / Area Authority ,declare that all hazards have been identified and all control measures are in I the Field Engineer/Operator confirms that all hazards identified and all control measures specified are in place
place and it is now safe for the work specified on this permit to be performed and is valid. and it is now safe to carry out the work specified on this permit.
Name Signature Designation Date Time Name Signature Designation Date Time
I the Performing Authority, have read and understood the above conditions and precautions. I accept responsibility for carrying out the work as specified.I will ensure the persons under my control read,understand and comply with
these conditions and precautions.I will notify the Operation Shift Incharge / Area Authority on completion or interruption of this work.
From:
To:
Performing Authority
9 Permit Sign of
PermitPerforming Authority I declare that all persons have been withdrawn and that all tools,plant and equipment
used have been removed and the site left in a safe clean and tidy condition.
I the Shift Incharge / Area Authority declare the work task is :- Complete Incomplete Isolations/Overrides can be removed:
1 DRIVERS/VEHICLE DETAILS
Applicant:
Access Route:
Entry Purpose:
I the Authorised Person have checked the vehicle against the check list/standard and declare the vehicle meets the criteria for vehicle entry
Site Engineer/Associate Signature Designation Date Time
Safety Systems or Devices that may be obstructedd or compromised Details contingency plan or additional requirements
4 CONTROLS
Correct Fire Extinguisher in vehicle: Continuous Gas Test required Site road plan attached :
pre Entry Gas Test required: Periodic Gas Test required: Route barriers required and in place:
Driver/Crew Site Induction Carried out: Site escort required and available: Certificate of explosive in place:
Loose items on vehicle made secure: Driver aware of site speed limit; Valid Lifting Certificates in place:
Anti-Static bonding in place: Road worthiness : Driver aware of Site route hazards:
6 ASSOCIATED PERMITS
Type Number Type Number Type Number
8 SIGN ON
Vehicle driver/attendant: do you understand the requirements of this permit: Are you aware of and understand the site safety rules:
Name ( Driver/Attendant) Signature Designation Date Time
I am aware of my responsibilities as escort for the vehicle identified in Section 1 of this certificate
Name ( Site Engineer/Associate ) Signature Designation Date Time
9 WORK COMPLETE
I the Site Engineer/Associate confirm the following:
The work is complete: The work site is clean and tidy: All equipment has been removed: The vehicle has been removed:
I the SBU/Sectional Head confirm all activities associated with this vehicle is complete and the site is clear
Plant/System to be isolated:
2 ISOLATION CONTROL
HAZARDS and PRECAUTIONS
Hazards:
Precautions:
SAFETY SYSTEMS
What systems or devices will be
compromised:
Detail contingency plans:
HV ISOLATION
HV Isolation required: Certificate Number: Switching Plan/Procedure Number:
ASSOCIATED PERMITS/CERTIFICATES
Type Date Issued Description of work Date Cancelled Shift Incharge / Area Signature
Authority Name
APPROVAL TO ISOLATE
I the Operation Shift Incharge / Area Authority declare that the plant/equipment identified in Section 1 is safe and available for isolations to be made in accordance with SSL safe Work Practice on
Process/Mechanical and Electrical isolations.The isolations to be applied are listed in section 2a(Isolations record).
Name: Signature: Date: Time hrs
ISOLATION CONFIRMATION
I the Shift Incharge / Area Authority declare that the isolations listed in 2a (Isolation record sheet) are in place and tagged and the plant/equipment described in Section 1 is now in a safe condition
for work to commence.
4 DE-ISOLATION CONTROL
Sanction to Test:I the Operation Shift Incharge / Area Authority authorise the temporary de-isolation for test purpose for -the equipment identified in the attached 2a (isolation record).
De-Isolation:I the Performing Authority declare that the work carried out under this certificate is now complete and all concerned parties have informed and isolations associated with this
isolation certificate can now be removed.
Return to Service:I the Shift Incharge / Area Authority declare that all concerned Certificates have been signed of and relevant work parties have been informed that work authorisation is
withdrawn and isolations under this certificate have been removed.The plan/equipment can be returned to normal service. This Isolation Certificate is now Cancelled.
All
De-Registration:The permit register has now been updated to show that this Isolation Certificate has been cancelled and normal operations can safely proceed.
6 AUDIT RECORD
Audit has been carried out on this Isolation Certificate
Name: Signed: Date: Time: hrs
Title of Auditor:
ISOLATION RECORD SHEET No.SSL/IRS/
1 ISOLATION REQUEST
Plant/System to be
isolated
Isolation Certificate No
2a ISOLATION RECORD
ELECTRICAL ISOLATIONS
SANCTION TO TEST
ISOLATION DE-ISOLATION
DE-ISOLATION RE-ISOLATION
Item Open/ Lock Name & Name & Name & Name &
No Tag No. Description Closed Locked no. Tagged Date Time Sign Date Time Sign Date Time Sign Date Time Sign
No Tag No. Item Open/ Locked Lock Tagged Date Time Name & Date Time Name & Date Time Name & Date Time Name &
Description Closed no. Sign Sign Sign Sign
INSTRUMENT ISOLATIONS
SANCTION TO TEST
ISOLATION DE-ISOLATION
DE-ISOLATION RE-ISOLATION
Item Open/ Lock Name & Name & Name & Name &
No Tag No. Description Closed Locked no. Tagged Date Time Sign Date Time Sign Date Time Sign Date Time Sign
Isolation Requirements (Process & Disconnect Earthed Fuse Removed Proved Dead
Mechanical)
PERSONNEL RECORD SHEET
Work to
be Done
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11
12
13
14
15
16
17
18
19
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I the Performing Authority certify that all persons involved in this work are aware about the SOP / SMP / SWP of the Job. Relevant Tool Box Talk has been done for the said work and all
personnel have been informed about the Hazards of the Job. All relevant precautions have been taken and relevant certificates taken for the said work and Personal Locks Locks are available
with all listed persons. For height jobs I have checked that no person involved is without Height Pass.
WORK-AT HEIGHT CERTIFICATE No.:SSL/WAH/
1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA (Not Applicable) Valid for a shift-After This permit Renewal Required
Note : ( Separate sheet to be attached in case of insufficient space above or change of persons during work)
Name of the working Agency
2 Hazards Identified
Fall from height Unguarded Opening Heavy Lifts Excavation Collapse Steam Improper placement of ladder
Fall of material Ackward Access Improper scaffold Mobile access platform Pressurised Pipework Temporary platform
Slipping Hazards Tripping Hazard Inadequate Lighting Simultaneous Opn Loose Objects at height Collapse of structure
3 Controls in Place
A Height pass Safety harness with double lanyard Tested scaffold with tagging Hand rails Roof holes hard baricadded
Signs & Barriers Fall arrestors Safe Access/Egress Toe baords Vertical lifelines
MSDS Precautions Additional Lighting Outrggier incase of mobile scaffold Lifting plan/Equipment Horizontal lifeline
Drained Safety net Approach ladder Secure Loose Objects Emergency rescue plan
Simultaneous opn identified and Risk accessment done Cage for fixed ladder > 2.5 m Crawling ladder Supervsion
B Additional PPEs Standards - Helmets, Safety Shoes and Safety Goggles are mandatory
Leather Gloves Electrical Gloves Cotton Gloves PVC Gloves Heat Resistant Gloves
Maintenance Gloves Aluminium Suit Chemical Splash sheild Leg Guard Face Shield
Dust Mask/SCBA Ascendor/Dyscendor /Rope Crab Safety Harness Steam resistant gloves & Suit Tool Box Meeting
C Job safety Analysis HIRADeC are mandatory for all work associated with safety Systems HIRADeC & SWP/WI/SOP/SMP No:
I/we agree this work can proceed provided all the above identified controls are in place and the precautions adhered to by the work party
5 Issue
I the Shift In charge,declare that all hazards have been identified and all control measures are in place and it is now safe for the I the Field Engineer/ Operator confirms that all hazards identified and all control measures specified are in place
work specified on this permit to be performed and is valid. and it is now safe to carry out the work specified on this permit.
From : To : From : To : hrs
hrs hrs hrs
Name ( Print) Signature Designation Date Time Name (Print) Signature Designation Date Time
I the performing Authority, have read and understood the above conditions and precautions. I accept responsibility for carrying out the work as specified.I will ensure the persons under my control read,understand and comply with these conditions
and precautions.I will notify the Area Authority on completion or interruption of this work.
6 Certificate Renewal
Date:
From:
To:
Receiving Authority
7 Certificate Sign of
Performing Authority: I declare that all persons have been withdrawn and that all tools,plant and equipment used have been
removed and the site left in a safe clean and tidy condition.
1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA(Not Applicable) Valid for a shift and it is restricted upto 6 pm only
Test for: LEL O2: Toxic: CO: Other: Test Equipment used:
2 Isolation Required Process/Mechanical Isolations: Permit. No. Electrical/Instrument Isolation: Permit. No.
Dropped Objects: Slipping Hazard: Tripping Hazard: Hydrocarbon : Heat: Airborne Particles e.g. Dust:
:
Entrapment: Engulfment: Flammable Material Adverse Weather: Traffic: Inadequate Isolations:
Inadequate Lighting Unguarded Opening: Radioactive Source Simultaneous Opn Other Hazards:
Signs & Barriers Walky Talky Available & Tested: Safety Harness & lifeline: Isolation in Place & verified: Inhibits/Overrides Required
Ventilation Provided Additional Lighting in Place: Face Mask with Filter : Ear Protection: Chemical suit:
Additional PPES Fire service Informed: Ambulance Informed 24 volt lighting source Emergency preparedness
Exhaust & Blower Manhole opened Emergency exit Additional control required
5 Authorisation for the Initial Testing and Inspection: SBU/ Sectional Head Project In Charge
The work to test and inspect the confined space can proceed provided all the above identified controls are in place and precautions being adhered to.
Note: This activity must be carried out in accordance with the guideline for confined space entry
I the Shift Incharge / Area Authority declare that all controls as specified above are in place.The Authorised
I the Authorised Gas Tester, have read and understand the above conditions and precautions specified.I accept
Gas Tester can, in accordance with the controls and precautions, test the space and if conditions meet the responsibility for carryig out atmospheric testing and inspection of the nominated confined space.I will ensure the
approved criteria,they can enter the space for the purpose of inspecting to establish the suitability of the
space for work to be performed. persons under my control read and understand an comply with these conditions and precautions.
Designation: Designation:
7 Initial Atmosphere /Gas Test Results: (Successive Atmospheric /Gas Tests are to be carried out as indicated below)
Agent Entry without BA Entry with BA Date Time Result Name Signature
Other
8 Permits and HIRADeC Associated With this Entry permit and Additional Controls
HIRADeC No: HIRADeC are Mandatory for all work associated with Confined Space Entry
Ventilation Required: Entry with BA Only: Entry with Airline and Hood: Toolbox Talk:
Designation: Designation:
10 Certificate Renewal
Date:
From(Time):
To(Time):
Shift In Charge
Performing Authority
11 Certificate Closure
Performing Authority:
I declare that all personnel have been withdrawn, Permits closure and that all tools and equipment used have been removed from the confined space associated with this certificate and the area left
in a safe clean and tidy condition.
Thw Work is Complete: The Work is Incomplete: The status of the work being:
Shift incharge/Area Authority:This permit is now void and no further entry is permitted
LOTO Key No
Switching Programme Attached: Isolation: De-isolation:
I the Performing Authority declare that the above equipment preparations and precautions have been adhered to. I will abide by the conditions of the attached
SOP/SMP/SWP/WI
Name
2 DE-ISOLATION
REQUEST FOR DE-ISOLATION -PERFORMING AUTHORITY
Name
I CONFIRM DE-ISOLATION COMPLETE -THE EQUIPMENT CAN BE RESTORED TO NORMAL OPERATING CONDITION
Name
1 SPECIFICATION OF EXCAVATION
Applicant: Designation Company
Area/Location:
Description of Work:
Tools/Equipment to be used:
2 HAZARDS:
Confined Space Tripping Hazard Excavation Collapse Toxic Gas Fumes Heavy Lifts Hazardous Substance
High Pressure jet Simultaneous Opn Unguarded Opening: Working at Height: Steam: Pressurised Pipework:
Slipping Hazard: Awkward access: Flammable materials Hydrocarbon area: Noise: Pressurised Hose failure:
Inadequate Lighting Dropped Object: Radioactive source: Static electricity: Vibration: Electrical hazard
Other Hazards:
3 CONTROLS
Drawings are attached to certificates: Underground service drawing checked: Safety barriers required/in place:
work/site area Gas Test required: Driver/crew Site Induction carried out: Shoring required/available at the site:
Access/Escape Route(s) identified: Valid lifting Certified in place: Driver aware of site route hazards:
Additional lighting available /in place: Fire /Emergency Equipment available: Additional PPE available:
Electrical Systems in Excavation Area: Are drawings available to show location/depth of cables: Can the Systems be safely isolated:
Mechanical Maint Systems in Excavation Area: Are drawings available to show location/depth of pipework etc. Can the Systems be safely isolated:
Process/Utility Systems in Excavation Area: Are drawings available to show location/depth of facilities: Can the Systems be safely isolated:
Instrumentation Equipment in Excavation Area: Are drawings available to show location/depth of equipment: Can the Systems be safely isolated:
IT & Telecom Equipment in Excavation Area: Are drawings available to show location/depth of equipment: Can the Systems be safely isolated:
I declare that the above checks have been carried out,the relevant isolation and controls are in place ready for the excavation work identified as above.
4 ASSOCIATED PERMITS/CERTIFICATES:
Type Number Type Number Type Number
6 ISSUE
I,the Shift In Charge declare that all the hazards have been identified and all controls are in place and it is now safe for the sxavation /penetration work to proceed
7 Certificate RE ISSUE
Date:
From:
To:
Performing Authority
8 WORK COMPLETE
I the Shift In Charge confirm all activities associated with this excavation work are complete.
The excavation is Open and barriers erected aroud this excavation site: The excavation is Closed and the work site clean and tidy: