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PERMIT to WORK
1. Area
2. Date
3. Work to be Done
4. Valid From
5. Valid To
6. Company
7. Man in Charge
8. No of Men
9. Safety Precautions
10. Safety Planning Certificate (cancelled if alarm sounds)
I have inspected the above job which has been safely prepared according to requirements of a safety planning
certificate
Signed ........................................
11. Approval of Permit to Work
I am satisfied that this permit is properly authorised, that safe access is provided, and that all persons affected by this
job have been informed
Signed ........................................
12. Electrical Equipment
All power has been isolated/locked/tagged/tried*
Circuits are live for troubleshooting only
Signed ........................................
13. Acceptance of Permit to Work