work permit example pdf

Specialized Work Permit

Authorization for High-Risk Work

Section 1: Permit & Job Information

Project / Job Title

Permit No.

Work Area / Facility

Specific Location / Equipment ID

Valid From Date

Valid From Time

Valid To Date

Valid To Time

Section 2: Scope of Work & Personnel

Detailed Description of High-Risk Work to be Performed

Work Supervisor / Applicant Name

Authorized Person Name

Additional Crew Members

Section 3: High-Risk Hazard Checklist

Confined Space Entry Hot Work (Welding/Cutting) Energized Electrical Work (Arc Flash) Lockout/Tagout (LOTO) Working at Height / Elevated Work Excavation / Breaking Ground Work in Explosive Atmosphere Work on Critical Systems Hazardous Chemical Handling

Specific Hazards Identified

Section 4: Control Measures & Required PPE

Required Control Measures

Required Personal Protective Equipment (PPE)

LOTO Details (if applicable)

Section 5: Authorization & Acceptance

Permit Issuer

Name

Signature

Date & Time

Work Supervisor / Applicant

Name

Signature

Date & Time

Section 6: Permit Closure & Handover

I hereby confirm that all work is completed and the work area has been left in a safe condition.

Permit Closed By (Work Supervisor)

Name

Signature

Date & Time

Handover Accepted By (Area Supervisor)

Name

Signature

Date & Time

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