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2017
1. Issue To :
A. Name…………………………..Dept…………………….SCC No…………………………………
B. Name…………………………..Dept…………………….SCC No…………………………………
C.
2. (A) Name of the Equipment………………………………………………….
(B) Details of Work………………………………………………………………….………….
……………………………………………………………………………..
3. Clearance : I hereby declare that it is electrically safe to work on the above mentioned equipment which
is isolated from all live sources, tested dead discharged and is connected to earth at the following points
(a) Point of Earthings
(b) Related P.T. is drawn out or primary and secondary fuses / links have been taken out
(c) LOCK Number & DANGER TAGs are provided as mentioned below:
Sr.No. Lock Numbers Location
Name :…………………………………Desig………………………….Dept………………….
SCC No……………………..Date…………….Time…………………..Signature ……………
4. Receipt: I hereby declare that I accept responsibility for carrying out the work on the equipment detailed
above and no attempt will be made by me or by the men under my charge to carry out work on any other
equipment. I have read the instructions given on the back of this permit and follow all the safety rules during the
work
A. Name ………………Dept………SCC No…………. B. Name …………Dept………SCC No………….
Date…………….…..Time……….Sign………….… IMPORTANT INSTRUCTION Date…………....Time……….Sign………….…
Upto 650V – Officers/Foreman/Chargemen with Rule-3 authorization of Indian Electricity rule
5. Cancellation Certificate: I hereby declare that the work for which this clearance was issued is now
1956.
completed / suspended and all man under my charge have been withdrawn. Tools , tackles and temporary
Upto 6.6KV – Officers / Foreman having valid SSC
earthing connections are all removed. I also declare that this clearance hereby stands cancelled and the job will
Above
not be started again6.6KV
without– taking
Experienced
a freshofficers with valid SSC
clearance.
A. Name ………………Dept………SCC No…………. B. Name ……………Dept………SCC No………….
1. List of Electrical Safety Items
Date…………….….Time……….Sign………….… Date……………...Time……….Sign………….…
Sl.No.
6. Restoration ofSafety Appliances
Power: / Tools all the
I have checked Uses
copies of this clearance form for cancellation of individual
work01permits issued vide each of the copies. I hereby accept responsibility of restoring power as per restoration
02
procedure and all temporary earthing, Danger tags has been removed and PT if withdrawn put in place. I have
also checked the megger value at the point…………………………………………………………………
IMPORTANT INSTRUCTION
Page 1 of 2
1. Authorisation for Issue, Receipt and Cancellation of this clearance is limited to the person in the
relevant voltage and over & above following hierarchical level as mentioned below :
Upto 440V – Officers/Foreman/Chargemen with Rule-3 authorization of Indian Electricity rule
1956.
Upto 6.6KV – Officers / Foreman having valid SSC
Above 6.6KV – Experienced officers with valid SSC
Page 2 of 2