[Type here]
Master Permit to Work
Site Name:
Permit Number:
Permit Requester:
P1
Phone Number:
Signature:
Job Number / Request No:
3. Working at Height Certificate
4. Additional Permits supporting this Master Permit
1. Detailed description of work to be carried out
This section to be completed by Competent Person to sign work at height certificates. A
certificate must be raised all work where a person could potentially fall more than 1.8m.
This includes the potential to fall into a pit or trench. Work on Roof / scaffold /
MEWP/cherry pickers, etc must be supported by a specific WAH Permit.
Permit Type
P2 Asbestos
P3 Confined Spaces
Equipment to be used
P4 Electrical Isolation (P4a/P4b)
Ladder
Work location:
PTW
Start
Date
PTW
Start
Time
PTW
End
Date
PTW
End
Time
Are fire system isolations required?

Podium Step
Fall protection (People & Materials)
P8 Mechanical Systems (P8a)


Tied ladder
Barriers/
Cones
Traffic
Management
P9 Pressure Systems
P10 Working at Height
P11 Limitation of Access

Warning
notices

Diversion of
pedestrians
P12 Transfer of System Control
Trained
Operator


Others (Pls specify):

Are there any additional hazards that will be generated by the work at height e.g.
overhead cables?
hours
Permit Number
P5 Excavation
P6 Fire Safety System Isolation
P7 Hot work
Additional Safeguards – tick those to be used
Method
Statement /
SSoW
reference:
Site Inspections will be carried out at intervals of

Other (specify)
Safety Documentation Attached:
COSHH
Assessment
Step ladder
Other
(Pls specify)
Footed ladder
Permit valid for not more than a work shift
Risk Assessment
reference:

Tick
5. Authorisation by Permit Issuer (Authorised/Competent Person)
To be signed by competent person issuing permit
Name
Date
Signature
Time (24hr)
6. Acceptance by Permit Holder
YES / NO
(To be completed by person responsible for the work, prior to commencing)
Other details (list any other safety precautions required):
2. Personal Protective Equipment / Clothing
To be signed by the senior person undertaking the works described in
section.1. This person is responsible ensuring this and any supporting
permits are displayed at the place of work.
7. Completion of Work
Tick
Safety
glasses
Safety
visor
Hearing
protection
Safety
shoes
Safety
gloves





Person undertaking the works is to complete the permit to work and sign all
copies, with agreement of the Permit Issuer having checked that the work is
completed and the requirements of the closure have been met
I declare that all persons, equipment, tools and instruments under my control have been
withdrawn and that the works detailed above have been:
Specify
type
Tick
(i) Satisfactorily completed
Tick
High
visibility
clothing
Protective
clothing


Specify
type
Other PPEs (Pls specify):
1/1 - APC-HSE-FORM-00532P1
Dust mask
Half/full
face mask
Hard /
bump hat




(ii) Stopped and abandoned, and that the
system has been made safe pending further
works

Signature
Name
Signature
Date
Time
8. PERMIT CANCELLATION
I declare that the work detailed above:
Tick

(i) Is completed
(ii) Is not completed. All works are to stop with immediate
effect.
Reason for stop work (e.g. end of shift, unsafe condition):
_______________________________________

Name of Permit Holder
(Requestor):
Work area/equipment returned to a safe status with NO hazards remaining
in respect of these works. All personnel, work equipment and materials
have been withdrawn as appropriate.
Date:
Name of
Permit Issuer
Signature
Time (24hr)
Date
Time (24hr)
Version 1 / Date of Issue 12 Sep 17