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Working at Height Permit R1

This document is a working at height permit that outlines safety precautions for work being performed above ground level. It lists the contractor and site details, a description of the work, supervision responsibilities, required safety equipment and its condition. It also includes a checklist of 15 safety precautions to be followed and confirms that all work will follow project safety rules and be executed under supervision. Sign off is required from the work performing authority, site engineer and permit issuing authority to approve and cancel the permit once work is complete.

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tamuthu
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76 views1 page

Working at Height Permit R1

This document is a working at height permit that outlines safety precautions for work being performed above ground level. It lists the contractor and site details, a description of the work, supervision responsibilities, required safety equipment and its condition. It also includes a checklist of 15 safety precautions to be followed and confirms that all work will follow project safety rules and be executed under supervision. Sign off is required from the work performing authority, site engineer and permit issuing authority to approve and cancel the permit once work is complete.

Uploaded by

tamuthu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Contractor name: Permit number:

WORKING AT HEIGHT PERMIT


Area: _________________________________________ _ Date: ___/___/____ Time: ______ _ __
(Area description must be precise – Attach Drawing & Job Safety Analysis)
Name of Site Engineer (Permit Requesting Authority): _________________________ Sign: _________ __
Name of Safety Officer:______________________________ Sign: ________ __
Name of Work Performing contractor: __________________ __ ____
Name of Cont. Site In charge: ______________ ___________ Contact Number:____________ ____
Description of work: _______________________ _____________________________________ __
_________________________________________ ___________________________________ _ __
Work Execution Date: ___________ __ Time Valid From: ____________ To: _____________ ___
The above signing person will be responsible to ensure that the above described work will be done under all
the safety precaution mentioned on the PTW and required by the Project.

The following precautions are to be taken


Not
No Item Yes
Required
1 Scaffolding with valid tag available for use
2 Safety Harness/belt checked and in working condition
3 Safety shoes (nonslip), Helmet with chin strip available with employees.
4 All lifting / tightening tools, hand tools /equipment checked and in good condition.
5 Access and exist marked and without obstruction.
6 Lighting arrangement adequate.
7 Unwanted and rubbish material removed from working platform.
Electrical cable/ welding hose / compressed air hose properly secured and lay down without
8
obstruction.
9 Signboards provided on working platforms.
10 Employees aware about hazards and safe working practices while working at height.
11 Protective plastic caps or clothing provided to extended parts of scaffolds.
12 Proper ladder for access to the working platform
13 Provided hand rails and mid rails for the working platform
14 Tie in provided for every 10 m height
15 Brazing is provided for scaffolding
16 Others

Reviewed & Approved By TCE (Permit Issuing Authority):


Safety Officer : _____________ __ Sign: __________ Date: __ ___Time ___ _ __
Site Engineer: _____________ ___ Sign: __________ Date: __ ___Time ___ _ __

I understand the precaution to be taken as described above and as per Project requirement & here by
confirm that Work will be executed under my supervision by following all precaution & Safety Rules.

Name of Work Performing Authority: __ __________Sign: __________ Date: __ __Time___ __


Permit Cancellation:
I hereby declare that the work is completed/ suspended, all workers under my control have been withdrawn
and the site restored to a safe tidy condition.

Name of Work Performing Authority : __ __________Sign: __________ Date: __ __Time___ __


Name of Site Engineer : __ __________Sign: __________ Date: __ _ _Time___ __
(Permit Requesting Authority)
Name of Engineer : __ __________Sign: __________ Date: __ _ _Time___ __
(Permit Issuing Authority)
(This Permit is valid only for the date it is issued)

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