COLD WORK PERMIT FORM(For Company Use Only)Permit Details Company Name Permit No Department / Section Date Issued Valid From Valid To (Max 8 hours) 1. Work Details Exact Location of Work Nature of Work Mechanical Work Electrical Work Instrument Work Piping Work Other: Job Description Equipment / Tools Used2. Personnel Permit Requester (Employee/Contractor) Work Operator(s) Supervisor Responsible Fire Watch Assigned (Name & Contact) 3. Mandatory Safety Checks (To be Verified Before Work Starts) Work area inspected and cleared Adequate lighting available LOTO (Lockout/Tagout) applied as required Fall protection provided if working at height Electrical isolation confirmed Tools and equipment inspected Adequate ventilation ensured Proper lifting equipment and procedure for heavy items PPE provided and used (helmet, gloves, goggles, respirator if required) Work area barricaded and safety signages posted 4. Gas Test Results (If Required) Oxygen Level (%) LEL (Explosive Gas) (%) Toxic Gas (Type/Reading) ppm Test Done By Date/Time 5. Authorization Permit Issuer Name Signature Date Area In-Charge Name Signature Date Work Operator Name Signature Date 6. Closure of Permit Completion Time Date Area inspected after completion Safe Unsafe Fire Watch duration completed (min 30 min) Yes No Permit Closed By Name Signature Date Download as PDF