Permit
Number
Limitation of Access
Site :
LIMITATION OF ACCESS
Plant Room
HV Switch
Room
Roof
Other
This form is used for work carried out in the vicinity of the apparatus, or areas of high risk when verbal instructions
are not considered sufficient. This form must not be used for work on apparatus for which an Electrical, Gas,
Pressure or a Hot Works Permit is required.
1. ISSUE
TO
In the employ of
Being a person, who has sufficient knowledge or experience to enable him to avoid danger, is hereby given
permission to carry out the work described below.
Location
Work or
Purpose
NO OTHER WORK SHALL BE CARRIED OUT
REMARKS
Service Line/Print
Name
Date
Time
Date
Time
Signature
ICT/Print Name
Signature*
Being the Area Authority
*When this form is used to give access to the machine room at Perceval House or Greenford Business Centre an
addition signature is required from a member of Ealing ICT.
Permit To Work – Limitation of Access Appendix A
Page 1
2. RECEIPT
Company/Print
Name
Date
Time
Recipients
Signature
Being the person to whom this form is issued (Performing Authority)
3. CLEARANCE
I hereby declare that the work for which this Limitation-of-Access is now suspended/completed and
that all men under my charge have been withdrawn.
Company/Print
Name
Date
Time
Recipients
Signature
Being the person to whom this form is issued (Performing Authority)
4. CANCELLATION
Service Line/Print
Name
Date
Time
Signature
Being the Area Authority on completion of the work the holder must surrender this Limitation-ofAccess as directed for cancellation, after which no work shall be done.
Permit To Work – Limitation of Access Appendix A
Page 2