SAFE WORK PERMIT FORMS SC SAF

HOT WORK PERMIT FM-30

IREO,SEC-58 GURGAON (No overwriting no alteration permitted)
HARYANA
Hot Work Permit .To be filled by permit seeker
Kindly issue a work permit for Hot Work
Location: Nature of activity to be executed:

Date: Time from_____ To ___________

I confirm the following Safety Status for carrying out the above hot work.
Descriptions Observation Descriptions Observation
(Yes/No/NA) (Yes/No/NA)
ELECTRICAL ISOLATION OF BARRIERS REQUIRED
WELD JOB IF REQUIRED
EQUIPMENT ISOLATED PORTABLE LIGHTING
WARNING SIGNS NO SMOKING OR NAKED FLAME
LOOKOUT SENTRY SCAFFOLDING ETC. REQUIRED
FIRE BLANKET TO BE USED FIRST AID KIT
WELDING SHIELD FOR WELDER FIRE EXTINGUISHER KEPT AT
WORK PLACE
FIRE PRECAUTION: AREA CLEAR REQUIRED PPE AVAILABLE
OF COMBUSTIBLES WELD SHIELD, APRON,S BOOTS
HAZARD MARKERS AND LIGHTS INSPECTION TAG PUT ON THE
REQUIRED WELDING M/C
BODY EARTH PROVIDED IN WELDING LEAD WITH LUGS &
WELDING M/C FREE OF JOINTS
WELDING APRON OTHERS (IF ANY)

Signature: _____________________ Name:__________________Designation: ________________

Company Name:___________________Date:_______________Time:_____________________
______________________________________________________________________________
To be filled by immediate superior of person applying for permit
I have verified the Safety status and permission to above mentioned is recommended.

Signature: ____________Name:_________________Designation:_____________________

Company Name:__________________Date:__________________Time:_____________________
________________________________________________________________________________
To be issued by the tower incharge of Civil Contractor.
Permission granted vide permit no:_________________Dated ________________Time:_________

Signed:__________________Name:___________________Designation___________________

Company Name:_________________Date:______________Designation:__________________
__________________________________________________________________________________
Disposal: I have completed the required work. Permit may be closed.
Signature of permit seeker__________________Date: ___________ Time:____________________
__________________________________________________________________________________
Closure: The safety status has been verified and the permit is closed.

Signature of permit issuer_________________Date:___________________Time:______________