Document No: RSIPL/EHS/WP/HO/01

PERMIT TO WORK REGISTER Revision No : 00

Date of Issue : 08.11.2022

Project Name

Register Name

S.N ISSUE DATE CLEARENCE

TYPE OF PERMIT PERMIT ISSUER PERMIT RECEIVER JOB DETAIL LOCATION REMARKS
O DATE

Prepared By: Approved By:

 Document No: RSIPL/EHS/WP/HO/02
COLD (General )WORK PERMIT Revision No : 00
Date of Issue : 08.11.2022

PTW Ref .No: Contractor:

Project Name: No. of Employees involved
Starting From Date Time Expected Completion Date Time
Activity:
A. 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
JSA 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 the this activities identified and assessed?
Working at height Scaffolding Pressure Test Chemical
Electrical Saw/Cold cut Hot Surface Tool & Equipments
Dust Lifting
Are permits associated requiring 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 to 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:
 Document No: RSIPL/EHS/WP/HO/02
COLD (General )WORK PERMIT Revision No : 00
Date of Issue : 08.11.2022
Permit Re-Validation

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Date Time Issuer Signature Receiver Signature Safety Signature Remarks
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This permit is valid for 7 days from the date of issue.

 Document No: RSIPL/EHS/WP/HO/03
EXCAVATION PERMIT Revision No : 00
Date of Issue : 08.11.2022
PTW Ref .No: Date:
Project Name: No. of Employee involved
Starting From Date Time Expected Completion Date Time
Excavation / Trench Depth Length: Width:
A. Work Description

Location of job to be performed

Tools/Equipment to be used

Identify risk associated this Excavation

Personnel Falling Underground Utilities Biological Noise
Falling Objects / Equipments Cave in (Collapse) Dust Vibration
Flood Adjacent Structure Heat Traffic
Other(Specify):
Precaution require to complete the work safely Yes No N/A
Is method statement attached with this permit?
Is risk assessment attached with this permit?
Are the equipments/machineries inspected and valid certification available for equipment & operator ?
Is the hard barrier given and safe distance (at least 1 meter from the edge of excavation) maintained?
Are type of soil identified? if yes mention below
Stable Rock Type A Type B Type C
Will the excavation be 5 or more feet deep and will personnel be entering? If yes, state below the
control measures been implemented :
Shoring Shielding Benching Sloping Details :
Will the excavation be 20 or more feet deep? If yes, Name of Professional Engineer ..............................
Are underground utilities checked below by means of appropriate detector through as build drawings,
and marked accordingly at the work location
Electrical Sewer Communications Storm water Gas Line
If underground utlities found, trial hole system (manual digging) is followed?
Are adequate inspection system followed for during, after excavation and backfilling?
Other (specify):
The following areas / items have been inspected by issuer and receiver
Access/Egress Danger/Warning Sign Lighting/Flickering Flag man
Detector (multi) As built Drawing Other (specify)
PPE Required for the activity
Helmet Safety Shoes Mechanical Gloves Safety Ear Plugs/ muff
Safety goggles Reflective Vest Dust Mask Safety clothes
Gumboot Others (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 to 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:
 Document No: RSIPL/EHS/WP/HO/03
EXCAVATION PERMIT Revision No : 00
Date of Issue : 08.11.2022

Permit Re-Validation

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Date Time Issuer Signature Receiver Signature Safety Signature Remarks
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This permit is valid for 7 days from the date of issue.

 Document No: RSIPL/EHS/WP/HO/04
WORK AT HEIGHT PERMIT Revision No : 00
Date of Issue : 08.11.2022

PTW Ref .No: Contractor:

Project Name: No. of Employees involved
Starting From Date Time Expected Completion Date Time
Scaffolding Ladder Aerial Lifts Roof Work Other; Specify:
A. Work Description

Location of job to be performed

Tools/Equipment to be used

Identify risk associated with Work At Height

Fall from Height Adverse Weather Flying particles Moving Vehicle/ Equipment
Falling Debris/ Objects Protruding objects, parts Tripping / Slipping Faulty Equipment/ Material
Fragile surface /Roof Work Under Below Near Overhead lines Near energized equipment
Other(Specify):
The following document must be attached with this permit
JSA Other (specify):
Precaution require to complete the work safely Yes No N/A
Have the risk control/s been implemented? if yes state below
Fall Protection : Guard Rails system Safety Net Toe Board
Fall restraint : Life Line Retractable Harness
Fall arrest : Harness with Shock absorber & Double Hook Harness without Shock absorber(less than 6 meter)
Have proper access/egress been provided?
Is wind speed greater than 32 km/h? If yes, do not proceed the activity
Are all floor openings at roof adequately covered/protected to prevent falling?
Is the scaffold erected and inspected by Certified person? (if no do not proceed the activity)
Is all lifting T&P been inspected by 3rd party?
Are the scaffold, ladder, Arial lift inspected it?
Name of Inspector: Date of Inspection:
Other (specify):
The following areas / items have been inspected by issuer and receiver
Danger/Warning Sign Scaffold Tag System Lighting Safety Barriers
Buddy System Rescue Material basket Other (specify:
PPE Required for the activity
Helmet with Chin strap 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 have been informed about the risk assessment results. 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 to 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:
 Document No: RSIPL/EHS/WP/HO/04
WORK AT HEIGHT PERMIT Revision No : 00
Date of Issue : 08.11.2022
Permit Re-Validation

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Date Time Issuer Signature Receiver Signature Safety Signature Remarks
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This permit is valid for 7 days from the date of issue.

 LIFTING OPERATION PERMIT Document No: RSIPL/EHS/WP/HO/05
Revision No : 00
Date of Issue : 08.11.2022

PTW Ref .No: Contractor:

Project Name: No. of Employees involved
Starting From Date Time Expected Completion Date Time
Lifting Equipment Mobile Crane Truck Mounted Overhead Crane Tower Crane
Details of Load Weight (approx.) Dimension (max) Quantity
Details of Equip. Serial No Valid Inspection Date Capacity (SWL)
A. Work Description

Location of job to be performed

Tools/Equipment to be used

Identify risk associated with Lifting work

Toppling/Tip Over/Turn Over Suspended Load High Wind Moving Vehicle/ Equipment
Falling Objects Over Load Tripping / Slipping Noise
Crushing Collapse Near Overhead lines Traffic
Adverse Weather Other(Specify):
The following document must be attached with this permit
JSA Lifting Plan (more than 10 ton) Other (specify):
Precaution require to complete the work safely Yes No N/A
Is the lifting equipment certified by accredited center or 3rd party?
Is the operator certified and hold valid license to carry out this activity?
Certified: Expiry Date : License: Expiry Date:
Are all accessories inspected (rigging arrangements)? if yes state below
Wire Rope Sling Web Sling Chain Sling Shackles Eye Bolt Other:
Is Load Charts Checked? Is the Load within Crane capability at the given radius of operation?
Is wind speed acceptable to proceed the activity? (stop if any dusty wind or more than 45km/h)
Other (specify):
The following areas / items have been inspected by issuer and receiver
Ground condition Danger/Warning Sign Signal man Safety Barriers
Tag line Rigger Outrigger (extended) Lighting
Out rigger Pad Spreader Beam Man/Material Basket (Certified)
PPE Required for the activity
Helmet Safety Shoes Mechanical Gloves 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 Issuer 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 to 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:
 LIFTING OPERATION PERMIT Document No: RSIPL/EHS/WP/HO/05
Revision No : 00
Date of Issue : 08.11.2022
Permit Re-Validation

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Date Time Issuer Signature Receiver Signature Safety Signature Remarks
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This permit is valid for 7 days from the date of issue.

 Document No: RSIPL/EHS/WP/HO/06
ELECTRICAL (ISOLATION) PERMIT Revision No : 00
Date of Issue : 08.11.2022

PTW Ref .No: Date:

Project Name: Number of Employees
Starting From Date Time Expected Completion Date Time
Energized Lines/Equipment De-Energized Line/ Equipment
A. Work Description

Location of job to be performed

Tool/Equipments to be used

Identify risk associated with this Electrical work

Electrocution Arc Flash Flying particles Noise
Falling Objects Protruding objects, parts Tripping / Slipping Electric shock
Fire Manual handling Electric Burn Near Overhead lines
Other(Specify):
The following document must be attached with this permit
JSA Other (specify):
Precaution require to complete the work safely Yes No N/A
Is the safe distance maintained? Yes No Voltage ........................... Distance ......................
Does the work require access to confined spaces? If yes, obtain a confined space entry permit
Have all possible sources of electrical power been isolated, locked and properly tagged (LOTO)?
Is below mentioned any one of Isolation in place and the isolation followed as per procedure?
Switch Out Lockout/ Tag out No. of Locks : ..................
Has it been confirmed by testing, that the lines / equipment are de-energized ?
Have tools and devices to be used been tested and adjusted?
Other (specify):
The following areas / items have been inspected by issuer and receiver
Fire Extinguisher Type ...................... Quantity................ Size....................
Access/Escape Route Danger/Waning Sign Lighting Safety Barriers
Stick Portable Radio Other (specify)
PPE Required for the activity
Helmet Safety Shoes Electrical Gloves Half Mask
Safety goggles Reflective Vest Dust Mask Safety clothes
Arc Flash Face
Face shield Arc flash cover all Safety Ear Plugs/muff
shield
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 have been informed about the risk assessment results. 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 Issuer 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 to 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:
 Document No: RSIPL/EHS/WP/HO/06
ELECTRICAL (ISOLATION) PERMIT Revision No : 00
Date of Issue : 08.11.2022
Permit Re-Validation

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

 Document No: RSIPL/EHS/WP/HO/07
HOT WORK PERMIT
Revision No : 00
Date of Issue : 08.11.2022
PTW Ref .No: Contractor:
Project Name: Number of employees involved
Starting From Date Time Expected Completion Date Time
Welding Bracing/Cutting/Grinding/Soldering
A. Work Description

Location of job to be performed

Tools/Equipment to be used

Identify risk associated with this Hot Work

Electrocution Arc flash Flying particles Noise
Falling Objects Protruding objects, parts Tripping / Slipping Electric shock
Fire/Spark Manual handling Hot burn Explosion
Health Hazard Fume /smoke Other(Specify):
The following document must be attached with this permit
JSA Other (specify):
Precaution require to complete the work safely Yes No N/A
Are you certified (welder) to undertake this work?
Is Equipment/Machine inspected and color coding available of the current month?
Are all combustible materials removed or shield from sparks?
Are the hoses inspected? Free from grease/oil cut/crack Fitting (Special clips)
Are regulator and Gauges inspected ? Defects/Broken Fitting Calibration

Are flash back arrestors provided?

Are the cylinders provided with cap, trolley, and chain and appropriate relieving valve?
Are emergency team available in place or contact number displayed at place?
Contact Numbers: 1............................. 2............................ 3................................
Have tools and devices to be used been tested and adjusted?
Other (specify):
The following areas / items have been inspected by issuer and receiver
Fire Extinguisher Type...................... Quantity................ Size....................
Fire Canopy Danger/Waning Sign Lighting Safety Barriers
Fire Watcher Fume Extractor/Ventilation Friction light Container (Rods)
Fire Blanket Sand Bucket Other (specify)
PPE Required for the activity
Helmet Safety Shoes Welding Gloves Face shield
Welding goggles Apron (Welding) Gas Mask Ear Plugs/muff
Welding shield Welding Clothes Others (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 to 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:
 HOT WORK PERMIT Document No: RSIPL/EHS/WP/HO/07
Revision No : 00
Date of Issue : 08.11.2022
Permit Re-Validation

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