| M.V./S.S.: |
POSITION |
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VALID FOR |
FROM |
hrs |
DATE: |
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PERIOD * |
TO |
hrs |
DATE: |
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| Location of work: |
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| Circuits involved: |
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| Special Conditions: |
Whether/option etc |
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| Personnel assigned to the work: |
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| We, the undersigned, are satisfied that the circuits described above: |
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| 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.+ |
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| Officer carrying out Work Signature : |
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| Chief Engineer’s Signature : |
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| Master’s Signature : |
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| Permit Cancellation : |
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| The work is completed and the equipment can be re-commissioned. |
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| Officer carrying out Work Signature : |
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| Date : |
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Time : |
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| * Valid only for time of work, not to exceed 8 hours.+ Delete as appropriate. |
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