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Document#: KAP-EHS-Form/003
Job Description
Safety Vest Cotton Gloves Safety Goggle Electrical Gloves Safety Harness
Observation during the job:
Will any SAFETY EQUIPMENT be out of service during the period of this work permit? YES NO
Are mechanical Lock Out / Tag Out necessary during the period of this work permit? YES NO
Are LV Electrical Lock Out / Tag Out necessary during the period of this work permit? YES NO
Are MV Electrical Lock Out / Tag Out necessary during the period of this work permit? YES NO
If “YES” in any of above questions, please fill and attach form EHS/004 to the Work Permit.
Special Fire guard required during the period of this work permit. YES NO
PERMIT VALID
From To
Maintenance Engineer Safety
Shift Engineer Requestor
Engineer
Date Time Date Time
Result of job:
Date:_________
___ Time:__________
Maintenance
Engineer____________________
Check list Yes No Sign Safety equipment is back Yes No Sign