Original Copy Permit No: H- 0001
Hot Work Permit
Joint job site inspection shall be conducted by Issuer and Receiver while issuing and closing the permit
Planned time
Date Number of worker(s) Department/Contractor
From Hrs. To Hrs.
Business unit Area and Equipment name Tag number
Details of work Work description:
(Receiver)
MOC Applicable Yes If ticked, write MOC serial number and approved date below. Attach MOC Certificate
Serial Number Approved Date
Which hazard has the highest potential to cause incidents.
JSA attached Yes
Hazards: Control measures:
Risk assessment
(Receiver)
Ensure that all tools & equipments are inspected. Yes
Hand tools Gas torch Soldering tool Electric tool Welding machine
Tools or equipments Fork lift Crane Man lift Excavator Generator
(Receiver) Pneumatic tool Hydraulic tool Grit blaster Compressor Hydro-jetting machine
Jack hammer Grinder Cartridge tool Heating pad Non-classified electric tool
Others (specify):
If ticked, write serial number below
If confined space is ticked, then obtain Fire and Emergency Department counter sign.
LTV procedure Excavation Confined space Fall control plan Floor Opening/Grating removal
Associated permits and
plans Electrical Lift/Rigging plan Radiography EHSS Critical Bypass Roof work plan
(Issuer)
Heavy Equipment Plan Chemical handling SWI attached SWI Number
Others (specify):
Work in potroom basement Yes N/A
Reduction room No: Location
Potroom/DC area
details
Mini dozer details Basement
(Receiver)
Others (specify):
ITEMS DONE N/A ITEMS DONE N/A
A Equipment isolated and LTV applied N Verify lifting equipment inspected
Grating, guardrail in place and secured
B Lockout details entered in log O
properly.
Check area/equipment condition for oil spills
C Depressurize/drain the equipment P
or combustible materials
Complete on location
D Purge/flush the equipment Q SDS available in work location
E Install blinds(Attach blind list) R Scaffolding inspected & tagged
F Ventilate the equipment S Hot tapping method of statement
Condition of area G Double block and bleed valve T Rally point or assembly point available
and equipment Will this work affect DCS or PLC, if yes
H Vents away from work site U
(Issuer) mitigation plan is prepared & attached
Out triggers of crane not placed over the
I V Grounding in place to avoid static electricity
gratings or other unsafe surfaces
J Radiation source is removed / locked W Men working basement notice posted
K Eye wash and safety shower working X Tap bath/metal not link with pot cell
L Valid equipment MA inspection sticker Y No red shell above basement work zone
M Physical restraint Z Grounding trolley in work area is connected
Helmet Hearing protection ( ) Surge protection (GFCI or ELCB)
Gloves ( ) Suit ( ) Flagman/Rigger
Mandatory PPE and Footwear ( ) Respirator ( ) Ventilation ( )
special protection Safety Glass/Goggles SCBA/Airline BA Barricades & warning signs
(Issuer)
Face shield Full body harness Reflective vest
Welding shield Arc flash resistant clothing Lifeline
Air horn Others (specify)
Special Interlock by-pass Yes N/A Dust/fibers Yes N/A Nearby rotating equipment Yes N/A
Complete on
instructions Flammable gas Yes N/A Fall hazard Yes N/A Trapped gas/ liquid Yes N/A
location
(Issuer) Poor illumination Yes N/A High noise Yes N/A High temperature Yes N/A
High pressure Yes N/A Radiation Yes N/A Automated fire suppression Yes N/A
1. If "Yes" then mitigation shall be identified in JSA.
2. If automated fire suppression system is "Yes" then obtain counter sign by Fire and Emergency Department.
Other instructions:
Fire protection Fire extinguisher (2 ten kg) Fire hose & nozzle Fire blanket
Complete
location
(Issuer) Cover drains & catch basin Spill containment Warning signs
on
Others (specify):
Fire watch Name & Authorization No. Badge No. Time Signature
(Receiver) Fire watch
Relief fire watch
Relief fire watch
Affected area / department Counter sign required Yes N/A Comments:
counter sign Area/Department Name Signature Date Time
(Issuer)
Type of test Initial Re-test Re-test Re-test Re-test Re-test
Gas test is mandatory
Oxygen 19.5%-23.5%
Complete on location
Gas Monitor Serial # Combustible LEL 0 %
H2S< 10 PPM
Monitor bump-tested CO < 25 PPM
Gas test Yes Cl2 <0.5 PPM
(Issuer) Monitor calibrated in SO2 <2 PPM
past 30 days Yes NH3 <25 PPM
Frequency of testing Signature
Date
Continuous monitoring Time
Yes N/A (If necessary use additional gas testing sheet as attachment)
If continuous monitoring is "Yes" then attach continuous monitoring log sheet for hot work
Time issued:
Date issued:
From: To:
Permit Issuer Permit Receiver
Authorization
(Issuer & Name: Name:
Receiver)
After joint site
ID #: Authorization No. ID #: Authorization No.
visit
Signature: Signature:
Contact method and number: Contact method and number:
Permit Issuer Permit Receiver
Name: Name:
Complete on location
Duration From: To:
Extension or ID #: Authorization No. ID #: Authorization No.
Endorsement
Signature: Contact Signature: Contact
(Issuer &
Receiver) Name: Name:
Duration From: To:
ID #: Authorization No.
ID #: Authorization No.
Signature: Contact Signature: Contact
Job Completion - Complete on location
Items N/A Yes No Name Signature Date Time
Is work completed?
Receiver Is worksite cleaned and made safe
Locks removed
EHSS bypass normalized
Worksite has been inspected
Issuer Safety devices returned to service
Locks removed
MSHEM-02.07-Work Permits-Rev.7 Emergency Number: RAK: 013 350 9111 Mine: 013 350 9777
