Permit to Work on Electric Circuits

Permit to Work on Electric Circuits

M.V./S.S.: POSITION Page 1 of 1
VALID FOR FROM hrs DATE:
PERIOD * TO hrs DATE:
Location of work:
Circuits involved:
Special Conditions: Whether/option etc
Personnel assigned to the work:
We, the undersigned, are satisfied that the circuits described above:
a Have been Isolated and that it is safe for the work outlined to commence.+
b Lock-out / Tag-out Procedures complied with. +
c Cannot be Isolated but the special precautions are adequate and that it is safe for the work to commence.+
Officer carrying out Work Signature :
Chief Engineer’s Signature :
Master’s Signature :
Permit Cancellation :
The work is completed and the equipment can be re-commissioned.
Officer carrying out Work Signature :
Date : Time :
* Valid only for time of work, not to exceed 8 hours.+ Delete as appropriate.

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