CIVIL WORK PERMIT

Name of site: Job Description: _Area/location of site: ------------------------Date: Permit No-

__________________________________________________________________________________ ______________ Permit required from ___________________ to time__________________ Name of the Performing Agency: ________________________________________ Risk Control measures to prevent Fall of Person Risk Control measures for avoiding Fall of Person
1. Whether safe access to work place is provided. 2. Is the work area away from the vicinity of moving objects? 3. Whether work platform is adequate with respect to strength and dimension. 4. Is JSA/Work Methodology attached with Permit? 5. Is the working platform fully boarded? 6. Are the workmen screened for working at height? 7. Only Medically fit personal engaged in work and list is available 8.Job Hazard is explained to all Concern through tool box talk meeting 9. Proper housekeeping is done 10 Scaffolder & supervisor trained to erect/Dismantle scaffold. 11. All lifting / tightening tools, equipment checked and in good condition. 12. Check soil condition, If soft soils- use wooden timber as a base plate 13 All Scaffold tubes, coupler, scaffold boards inspected prior to use. 14. Scaffold tubes- No bent, rust. Couplers- weakened by rust, damaged. 15. Scaffolder instructed to wear/attach safety belt all time and not to work under direct rain, during lightening, heavy wind. 16. Surrounding area 1 meter away from erection site barricaded and warning sign displayed at all location. 17. Power cable properly insulated and rooted at ground & top level. 18. All wooden ladders are in working order and no step rungs are missing. 19. Protective plastic caps or clothing provided to extended parts of erected scaffolds. 20. Ensure proper illumination in site & around chimney.

Done

Not Reqd

Remarks

Equipment Provided:
Safety Harness and lanyard anchored to independent rigid object Full body harness is used by all workmen engaged at height work safety net provided

Risk control measures for avoiding fall of Materials.

1. Work at more than one elevation at the same segment is restricted. 2. Walkways, aisles & all overhead work place cleared of loose material. 3. Whether all tools & tackles inspected before use. 4. Whether hand tools and handling materials secured against Accidental fall. 5. Workmen provided with bag/ box to carry bolt, nut & hand tools. 6. Whether area below, where the height being performed is cordoned And unauthorised entries are avoided.

Permit Requested By

Contractor:
Name : Designation : Signature :

SAFETY OFFICER :

Contractor:
Name : Designation : Signature :

Issuing Authority : section In Charge/Area In Charge: Name : Designation : Signature :

HSEM/HSEO : Name : Designation : Signature :

Closing of the Permit

Time---------- & Date-------------- at which the permit is closed Name of the issuing Authority: Designation: Signature:
Note: Frontline supervisor of the gang performing the activity should have PTW copy with him. One copy should be retained by the issuing Authority. The permit is valid till the issue time, extension of permit may suitably obtained before expiry of permit. Once the activities are over work place shall be left safe.