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Cold Work Permit Form

The document outlines a cold work permit that identifies risks, required precautions, inspections, and approvals for work. It requires listing the location, workers, equipment, identified risks, attached documents, inspections, required PPE, and sign-offs from the receiver, issuer, and contractor's safety officer.

Uploaded by

azozinlc
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
21 views

Cold Work Permit Form

The document outlines a cold work permit that identifies risks, required precautions, inspections, and approvals for work. It requires listing the location, workers, equipment, identified risks, attached documents, inspections, required PPE, and sign-offs from the receiver, issuer, and contractor's safety officer.

Uploaded by

azozinlc
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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COLD WORK PERMIT

PTW Ref .No: Contractor:


Project Name: No. of Employees involved
Starting From Date Time Expected Completion Date Time
Activity:
Work Description:

Location of job to be performed :


Tool/Equipment to be used:
Identify risk associated with this Cold Work
Fall from Height Adverse Weather Flying particles Moving Vehicle/ Equipment
Falling Debris/ Objects Protruding objects, parts Tripping / Slipping Faulty Tool/ Material
Noise Heat Vibration Poor Illumination
Other(Specify):
The following document must be attached with this permit
Method Statement Risk Assessment Job Safety Procedures Other (specify):
Precaution require to complete the work safely Yes No N/A
Have tools and devices to be used been tested and adjusted?
Have all hazards/hazardous related to this activity identified and assessed?
Working at height Scaffolding Pressure Test Chemical
Electrical Saw/Cold cut Hot Surface Tool & Equipments
Dust Lifting
Are permits associated require for this activity? if yes, mentioned below;
Hot Work Working At Height Excavation Electrical Confined Space to Entry
Other (specify):

The following areas / items have been inspected by issuer and receiver
Access/Egress Danger/Warning Sign Lighting Safety Barriers
Hand Tools Other (specify)
PPE Required for the activity
Helmet Safety Shoes Safety Gloves Safety Ear Plugs/muff
Safety goggles Reflective Vest Dust Mask Safety clothes
Other (Specify):
Issue and acceptance before work
Acceptance of Work Permission by the person in-charge (Receiver)
I certify that, I have read and verified this work permit and checklist. I am aware of the risks that can be exposed to. I commit that I will be in line
with all safety rules mentioned in work permit checklist and will not deflect any of them.
Permit Receiver Name: Signature/Date:
Authority to proceed by authorized person (Issuer)
I reviewed the work permission checklist and checked the working conditions. I have reviewed the all aspects of the task/activity and am satisfied
with the arrangements as detailed in the “risk assessment” have been put in place and certify that the activity detailed above is authorized to
proceed
Permit Issuer Name: Signature/Date:
Acknowledge by Contractor's Safety Engineer/Officer
Name : Signature/Date:
Clearance and cancellation after work or Suspension of permit
Clearance. (Site Manager)
All men, materials, tools equipment, housekeeping etc. under my charge have been withdrawn. The permitted work is complete / not complete.
Name: Signature/Date:
Suspension
This permit is suspended, I have notified the Authorized person specified that the work is not complete the area / equipment is not safe to use.
Name: Signature/Date:
COLD WORK PERMIT

List of additional precaution measures required (Supervision Consultant/ Contractor's Safety Engineer/ Officer)

1.

2.

3.

4.

5.

Permit Re-Validation

Sl. Contractor's
Date Time Issuer Signature Receiver Signature Remarks
No Safety Signature

This permit is valid for 7 days from the date of issue.

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