Permit Ref.

No:

General work permit

Project name Emergency Contact Number

Contractor name 1

Location of work to be
2
performed

Date 3
Labor Category

Description of work to be performed

From To
Permit validity period Date : …………… ..……………...
Time : ……………. .......................
Note : Please Mention Appropriate options in the below table YES / NO / Not Applicable - Y / N / NA
Sl no DESCRIPTION Y/N/NA Provide Inputs for each entry below

Work Area is free from any obstruction / hazards?

1
Sufficient lighting arrangement provided?
2
Scaffold / Ladder Inspected?
3
Energy Source Isolated / Disconnected If Any?
4
Electrical power supply, ELCB, Earthing and connection Checked?
5
Fire extinguisher provided for Hot Works?
6
Is the area cordon off / barricaded with display of Signage?
7
Equipment / Tools Inspected and tagged?
8
Safety Signage’s are in Place?
9
Is Personal protective equipment provided and being used?
10
Job briefing to all crew members?
11
Any special instructions that must be complied with -
12
I have checked and confirmed that the following safety requirements have been complied with. Safety Officer / Safety Coordinator has been informed to check
the working zone, Proper access to working zone is available, Adequate ventilation and lighting is made available. All worker are provided with the necessary
PPE, training & Tool Box Talk. Safe Work Procedure is available and briefed to the workers, Risk Assessment has been carried out and briefed to the workers.

Permit Raised and Checked

by Signature with Time
(Site Engineer/Supervisor)
Permit Approved by (Sec
Signature with Time
Incharge) Name:

Verification by (EHS
Signature with Time
Personnel) Name:

ACCEPTANCE BY JLL:
Accepted / Declined.
If declined, action required by contractor with agreed time line
I have inspected the above stated location and confirmed that the recommended safety measures are in place and the said location is safe for the work at the
point of inspection:-

JLL Representative Name: Signature with Time

TASK COMPLETED: Works have been completed and area checked
SIGNED: …………………………………(site enginner/ in charge) DATE : / / TIME:………..am/pm
Note:1.No activity to be carried during lightning, heavy wind /rain.
2.Copy of permit to be submitted to JLL. Concerned agencies are responsible for any unsafe act / conditions. Hard Copy of permit to be displayed at work spot.