Pioneer Project

PTW NO:-…………….….

Permit To Work - GENERAL

Permit Applicant : - …………………………………………………….……………………………………………………………………..
(Person Responsible For Performance 0f the Work (Name, & Company)
Name Of Contractor :-…………………………………………………………………………………..………………………………………….
Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : Date & Time Of Expiry: Permit Extension -

Applicant : Date / Time / Sign

Name ( in block letters) / date/ signature Date / Time / Sign

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of
extension required authorization as above is "MUST".
Date / Time / Sign
GENERAL WORK - Check Points
GENERAL Work: General work” means any work which is to be performed under controlled supervision and not included in PTW SOP.
Sr. No Measure Remarks
TBT to workmen regarding hazards and working procedure conducted (Attach Attendance)
1 YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 All activities shall be carried out under proper supervision YES NO N/A

4 Safety induction and medical screening done for fitness of involved workmen. YES NO N/A

5 Illumination of min 50LUX maintained at the work place. YES NO N/A

6 Safety and legal local norms strictly followed.(Distrubance to local community ) YES NO N/A

7 Any unfavorable weather condition like heavy rain, wind / thunder. YES NO N/A
All electrically operated tools used with due care only by skilled workers with appropriate
8 PPEs. YES NO N/A
Separate work permit obtained for Hot work, Height Work, Excavation, and confined space
9 etc.. YES NO N/A

10 High visibility cloth provided and used by workers during night work YES NO N/A
Proper communication system in place to inform emergency situation to project manager /
11 safety engineer. YES NO N/A

12 All emergency No's displayed at site and known to supervisor . YES NO N/A

13 Emergency vehical and first- aider with first-aid facility available at site. YES NO N/A

14 ID, mandatory and job specific PPEs are issued and usage ensured. YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
Earthing Emergency Vehicle Weather Condition Medical Fitness
PPE's Ventilation First - Aid Method Statement
Other (Please Specify):
Additional Safety Precaution / Remarks :-

Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as property. I will abide by the
recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : Mobile No:

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action
Contractor EHS Engineer / Manager : -
Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): Mobile No:
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures:

Client Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : Person responsible for Isolation :
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature
Physical verification of the closure of work is mandatory for sign off by
Work Completion Handover:
work release authority.
Notification of Client ( Site Manager/ Area Incharge):
Completion *In case of energy isolation, shall verify the completion of work, ask for
and verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.