HPM-WP-001

PERMIT TO WORK- GENERAL WORK

Permit No:

Section – I GENERAL DETAILS

Project Name LODHA PARK

Activity / Type of work

Area / Location
Date : Start Time : AM/PM End Time : AM/PM
Permit Applicant Name
No of Workers Involved
Contractor Name

Section – II PRECAUTIONS TO AVOID POTENTIAL HAZARDS

PRIOR TO COMMENCEMENT YES / NO PRIOR TO COMMENCEMENT YES / NO

Are all labours trained for the specific
job?
Tool box talk conducted?
Supervisor available full time?
PPE available to all workers?
Any activity producing high noise?
Is electricity going to be used?
All tools & equipment are in healthy
condition & thoroughly inspected?
Any pressurized vessels are going
to be used?
Any power tools/heat generating
tools are going to be used?
Is there any Hot work/Height work?

Section – III (Permit Requested by):

I request for a permit for the above mentioned work at the location specified above. I have personally
inspected the work place to ensure that requirements needed and precautionary measures as
mentioned above have been complied with.
Checked by
Name Designation Signature
Contractor site In charge

Authorized by CM Name Designation Signature

Authorized by HPM Name Designation Signature

Name Designation Signature

Authorized by SFS

Any Other Remarks :

Section – IV PERMIT CLOSURE (PLEASE ENSURE TO CLOSE THE PERMIT)

The above job is completed at ……..am/pm, and ensured that work area is cleaned & all materials are
removed. All work persons have left from site.

Permit Applicant (Name)……………………..Signature: ……………………..Date & Time: …………………..

The above work is completed, permit closed & permit submitted to HPM.

Authorized HPM (Name): ……………………….Signature: ……………………. Date & Time: ……………….…

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 HPM-WP-001

Annexure - 1: List of persons authorized to work for this activity.

SR Name of Workmen/Staff Trade Contractor Name Signature

No.

10

11

12

13

14

15

16

17

18

19

20

Note: No unauthorized person, other than listed above, shall be engaged in for this activity.

Name (Contractor Work In charge): …………………………………… Signature:

………………………………

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