Permit to Work on Electric Circuits

M.V./S.S.:

POSITION

Page 1 of 1

VALID FOR

FROM

hrs

DATE:

PERIOD *

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:

Have been Isolated and that it is safe for the work outlined to commence.+

Lock-out / Tag-out Procedures complied with. +

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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