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Confined Space Work Permit Template

This document is a confined space permit to work that outlines safety procedures and requirements for work taking place in a confined space. It provides details of the work order, location, contractor, description of work, required equipment, and names of those responsible for monitoring entry and exit from the space. It also specifies required personal protective equipment, common protective measures, gas testing requirements before and during the work, and sign-offs from the contractor and subcontractor to verify the site is safe to start and complete the work.

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NethiyaaRajendran
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372 views1 page

Confined Space Work Permit Template

This document is a confined space permit to work that outlines safety procedures and requirements for work taking place in a confined space. It provides details of the work order, location, contractor, description of work, required equipment, and names of those responsible for monitoring entry and exit from the space. It also specifies required personal protective equipment, common protective measures, gas testing requirements before and during the work, and sign-offs from the contractor and subcontractor to verify the site is safe to start and complete the work.

Uploaded by

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

PILLAR TRIBUTE ENVIRONMENT


21/1/2021

CONFINED SPACE PERMIT TO WORK REF:PTE/CSPTW

Work Order No: ________________ CONFINED SPACE WORK Confined Space Permit No:___________
Location: _ _ PERMIT Issue Date _______________________
SUBCONTRACTOR ______________________________ AREA OF W ORK _________________________________________
SUBCONTRACTOR

WORK STARTING DATE _____________ TIME ________ W ORK ENDING DATE ___________ TIME ___________________
TO BE FILLED BY

DESCRIPTION OF THE W ORK _____________________________________________________________________________


_________________________________________________________________________________________________________
WORK EQUIPMENT _______________________________________________________________________________________
Stand-by W watchman Name Fire W watchman Name _
Stand-by W watchman Name shall record in/out of personnel; No one is allowed to enter without the presence of the Stand-by
W watchman
Subcontractor receiving Authority Date Time
Subcontractor performing Authority Date Time

Has the equipment to be: YES NO N/A OTHER: YES NO N/A


Depressurized Are sewer, drain properly secured
Drained Is Site clear from combustible
Isolated by spading Is Fire Protection required
TO BE FILLED BY CONTRACTOR

Water flushed Is Fire Watch required


Ventilated by natural/mechanical Is Gas Tester required
Purged with inert gas/steam Specify how often gas tester is required
Is power cable to be disconnected Is control cable to be disconnected
Is wind direction to be considered Are warning notice/area restriction required
Other special precautions to be taken:
INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X):
□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves
□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask
□ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness
□ Dust Mask □ □ □ □ __________

COMMON PROTECTION EQUIPMENT ________________________________________________________________________


OTHER SAFETY MEASURES ________________________________________________________________________________
Contractor Issuing Authority Date Time

GAS ANALYSYS TEST DATE TIME DATE TIME DATE TIME DATE TIME
COMBUSTIBLE
TOXIC H2S
O2
OTHERS

Signature Authority Gas Tester:

Site Preparation completed and work can commence I understand the precaution to be taken as described above

Contractor Operating Authority Subcontractor Performing Authority

The W work is completed and working area cleared The Site has been checked and working Area accepted
CLOSURE

______________________________________ ________________________________________
Subcontractor performing Authority Contractor Operating Authority

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