PERMIT TO WORK

REQUEST - EDITED BY PERMIT TO WORK APPLICANT

Delivering of Expected starting Expected ending
protected area: date and time: date and time:
Number of Contractors
involved: Number of workers:
INSTALLATION OR EQUIPMENT OBJECT OF THE WORK:

WORK ACTIVITY DESCRIPTION:

A HAZARDOUS ENERGIES INVOLVED:

q Electric energy q Hydraulic energy q Thermal energy

VEHICLES AND EQUIPMENT USED:

See attached PRE-RISK ASSESSMENT, with the undertaken measures and personal and co
PERMIT TO WORK APPLICANT

Name: Company: Date and Time:

WORK RESPONSIBLE
Appointment of Work Responsible

Corresponds to Permit to Work Applicant? Yes

Name: Company: Date and Time:
 VALIDATION - EDITED BY PLANT MANAGER
LOCATION OF INSTALLATION OR EQUIPMENT:

SAFETY MEASURES ARE REQUIRED FOR THE FOLLOWING INSTALLATIONS AND/OR EQU

Request Approved? Yes

PLANT MANAGER

Name: Company: Date and Time:

 ANALYSIS DEFINITION AND IMPLEMENTATION - EDITED BY ENERGY CONTROL
WORK RESPONSIBLE
MANOEUVRES/VERIFICATION
Nr.

Description

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
C 16
11
12
13
14
15
16
17
…
LOCK OUT METHOD:

q Individual Control q Single Lock q Multiple Locks

See attached SCHEMEs and DRAWs, in order to identify isolation
ENERGY CONTROL COORDINATOR

Name: Company: Date and Time:

PERMIT TO WORK RESPONSIBLE
Appointment of Permit to Work Responsible

Corresponds to Energy Control Coordinator? Yes

 Name: Company: Date and Time:

WORK EXECUTION - EDITED BY PERMIT TO WORK RESPONSIBLE AND WORK RES

See attached SCHEME and DRAW, in order to identify working areas
FURTHER MEASURES TO MITIGATE INTERFERENCES RISK:

D
PERMIT TO WORK RESPONSIBLE

Name: Company: Date and Time:

WORK RESPONSIBLE

Name: Company: Date and Time:

WORK COMPLETION - EDITED BY WORK RESPONSIBLE, PERMIT TO WORK RESPO

WORK RESPONSIBLE

Name: Company: Date and Time:

PERMIT TO WORK RESPONSIBLE

Name: Company: Date and Time:

E
For the Permit to Work Responsible:

Go to the "B" section, in order to perform the down-up execution of manoeuv

The work is completed, the further safety measures were removed, the workers were sent away and the install
Name: Company: Date and Time:
PLANT MANAGER

Name: Company: Date and Time:

 Progressive number
Correlated Permits
Correlated LOTO Instructions

Expected ending Return of

date and time: protected area:
Evacuation time in case
of emergency:

q Thermal energy q Other

easures and personal and collective protection equipments

K APPLICANT

ate and Time: Signature:

ONSIBLE
rk Responsible

[ ] No [ ]
ate and Time: Signature:
LLATIONS AND/OR EQUIPMENT:

[ ] No [ ]
NAGER

ate and Time: Signature:

BY ENERGY CONTROL COORDINATOR AND PERMIT TO

ERIFICATION
Up-down Down-up
Type
Execution Execution
of Lock Tag
(PtW (PtW
isolat Nr. Nr.
Responsible Responsible
ion
) )

q Multiple Locks q LOTO Box

in order to identify isolation point
COORDINATOR

ate and Time: Signature:

RESPONSIBLE
o Work Responsible

[ ] No [ ]
ate and Time: Signature:

SIBLE AND WORK RESPONSIBLE

der to identify working areas assigned

RESPONSIBLE

ate and Time: Signature:

ONSIBLE

ate and Time: Signature:

RMIT TO WORK RESPONSIBLE AND PLANT MANAGER

ONSIBLE

ate and Time: Signature:

RESPONSIBLE

ate and Time: Signature:

ork Responsible:

wn-up execution of manoeuvres/verifications

ere sent away and the installation is available for normal operation
ate and Time: Signature:
NAGER

ate and Time: Signature: