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SAFE WORK PERMIT CLASS- D

FINOLEX INDUSTRIES LIMITED


CAPTIVE POWER PLANT,
GOLAP-RANPAR, RATNAGIRI.

SR. NO.

ORIGINAL COPY

MARK (V) WHEREVER APPLICABLE OR (X) WHEREVER NOT APPLICABLE.


ORIGINAL COPY SHALL BE KEPT AT THE JOB SITE UNTIL WORK IS
COMPLETE.

EXCAVATION, ROAD BLOCKAGE


SWP REQUESTED BY SHRI : ____________ SIGN :____________ DEPT : ____________ SWP REQUIRED AT : ______ON:_________
JOB AT PLANT / DEPT.:_______________ UNIT NO. ____________ LOCATION.____________________________________________
JOB DESCRIPTION (MENTION THE PURPOSE ALSO) :
A) EXCAVATION :________________________________________________________________________________________________
EQUIPMENT INVOLVED : POWER / HAND TOOL, ___________________________________
APPROX. DEPTH _______MTRS.
BACK FILLING DETAILS: ________________________________________________________________________________________
B)

ROAD
BLOCKAGE
:
(SPECIFY
_________________________________________________________________________

SWP ISSUED ON DATE : _______________AT:_______ HRS.

ROAD

NO.)

VALID UP TO ___________HRS.

PART 1 : FIRE & SAFETY DEPARTMENTS CLEARANCE:


- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED DRAWING OF THE FIRE HYDRANT SYSTEM.
( )
JOB CAN BE PERFORMED SINCE NO FIRE PIPELINE AND EQUIPMENT WOULD BE OBSTRUCTED.
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED DRAWING OF THE FIRE HYDRANT SYSTEM,
( )
AND SINCE FIRE PIPE LINE AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE PERFORMED WITH
EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: _______________________________________________________
______________________________________________________________________________________________________________
- SINCE ROAD NOS. ------------- WOULD BE BLOCKED ALTERNATIVE ROUTE NO.__________ FOR EMERGENCY MANAGEMENT
WOULD BE UTILISED, IF REQUIRED. ALL THE DETAILS NOTED AND INFORMED TO F & S STAFF.
SHIFT IN CHARGE FIRE & SAFETY: SIGN:___________________NAME:________________DATE:___________TIME:__________HRS
PART 2 : ELECTRICAL DEPARTMENTS CLEARANCE:
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED ELECTRICAL AND TELEPHONE CABLES
( )
NETWORK DRAWING. JOB CAN BE PERFORMED SINCE NO ELECTRICAL AND TELEPHONE CABLES AND EQUIPMENT
WOULD BE OBSTRUCTED.
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED ELECTRICAL AND TELEPHONE CABLES
( )
NETWORK DRAWING. SINCE THE NETWORK AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE
PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: _______________________________________
____________________________________________________________________________________________________________
SHIFT IN CHARGE ELECTRICAL DEPT: SIGN:_________________NAME:_______________DATE____________TIME:_________HRS

PART 3 : INSTRUMENTATION DEPARTMENTS CLEARANCE:


-

CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED INSTRUMENTATION CABLE NETWORK
( )
DRAWING. JOB CAN BE PERFORMED SINCE NO INSTRUMENTATION CABLES WOULD BE OBSTRUCTED.
CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED INSTRUMENTATION CABLES NETWORK
( )
DRAWING AND SINCE THE NETWORK AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE
PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS:_______________________________________
___________________________________________________________________________________________________________

SHIFT IN CHARGE INSTRUMENTATION DEPT: SIGN:______________NAME:____________DATE____________TIME:_________HRS


PART 4: CONSTRUCTION DEPARTMENTS. CLEARANCE:
- CHECKED THE PROPOSED AREA OF EXCAVATION, SURROUNDING BUILDING AND STRUCTURE AND UNDERGROUND
( )
PIPELINES. JOB SHOULD BE PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: _____________
_____________________________________________________________________________________________________________
ENGINEER CONSTRUCTION DEPT. : SIGN:_______________________NAME:____________DATE____________TIME:_________HRS
PART 5 : AREA INCHARGES CLEARANCE :
PERMITTED EXCAVATION DEPTH:___________ MTRS
INFORMED TO SECURITY
[ ]
BARICADING DETAILS: ____________________________________________________________________________________________
BACK FILLING DETAILS:___________________________________________________________________________________________
SPECIFIC INSTRUCTIONS (if any) : __________________________________________________________________________________
SAFE WORK PERMIT IS ISSUED AFTER CONSIDERING ALL SAFETY ASPECTS & ADOPTING NECESSARY SAFETY
PRECAUTIONS AND WILL BE EXECUTED BY ADOPTING SAFE WORK PROCEDURE. THE JOB, SAFE METHOD OF WORK, USE OF
PPE, HOUSE KEEPING, EMERGENCY PREPAREDNESS & RESPONSE PROCEDURE, COMMUNICATION MEDIA ETC ARE CLEARLY
EXPLAINED TO THE EXECUTING STAFF.
NAME OF SAFETY WATCH: SHRI _______________________
SIGN : ______________

NAME:__________________

DATE:________________ TIME :__________________HRS.

AUTHORISED OPERATIONS SATISFACTION

SIGN : _____________ NAME:___________________


DATE : ______________ TIME:__________________HRS.

AUTHORISED MAINTENANCE SATISFACTION

SWP EXTENSION
ALL PARAMETERS CHECKED AND FOUND OK. AND EXTENSION GIVEN FOR THIS PERMIT AND ENTRY
MADE
SR. DATE
NO.

SHIFT

FROM

TO

NAME OF
SAFETY WATCH

OPERATIONS SATISFACTION
SIGNATURE
NAME

AFTER ANY EMERGENCY OR STOPPAGE OF WORK FOR CERTAIN REASON ALL THE PARAMETERS OF THE SWP
ARE RECHECKED AND SINCE FOUND SATISFACTORY RESTART OF THE JOB IS ALLOWED AND ENTRY MADE.
JOB STOPPED FOR REASON :_______________________________________________________
AT : _______ HRS.

SR.
NO.

DATE

SHIFT

TIME
(HRS.)

MAINTENANCE SATISFACTION
SIGNATURE

HANDING OVER
THE JOB IS COMPLETED
THE JOB IS INCOMPLETE.
BACK FILLING DONE AS INSTRUCTED.
BARICADING REMOVED.
HOUSE KEEPING DONE.

NAME

OPERATIONS SATISFACTION
SIGNATURE

NAME

TAKING OVER
[ ]
[ ]
[ ]
[ ]
[ ]

WORK CHECKED.
HOUSEKEEPING DONE IS SATISFACTORY.

[ ]
[ ]

ROAD BLOCKAGE REMOVED, INFORMED


TO FIRE CONTROL ROOM AND SECURITY

PERMIT RETURNED.

WORK ACCEPTED

SIGN :____________NAME :______________


DATE : __________ TIME :_______________HRS.

SIGN : ___________ NAME:________________


DATE____________ TIME :_________________HRS.

AUTHORISED MAINTENANCE SATISFACTION

AUTHORISED OPERATIONS SATISFACTION

NOTE: THE INSTRUCTIONS MENTIONED ABOVE SHALL BE STRICTLY FOLLOWED. THE PERMIT IS NOT
VALID IN THE EVENT OF AN EMERGENCY. HOWEVER AFTER THE EMERGENCY IS OVER IT CAN BE
REVIVED AFTER RECHECKING FOR OPERATIONS SATISFACTION AND MAINTENANCE SATISFACTION.
THE PERMIT IS VALID FOR THE RESPECTIVE ROTATING SHIFT ONLY. IT CAN BE EXTENDED
SHIFTWISE TILL 0700 HRS NEXT MORNING.

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