WORK PERMIT – COLD WORK
System: HSEMS
Form No.:
Form Rev. No.:
Form Issue No.:
Form Issue Date:
Ref. #:
Date:
COLD WORK
Permit No.
Year
Serial number
6. SITE GAS TESTS (testing device must have valid calibration certificate)
1. SPECIFICATION OF WORK (by performing authority)
Project:
Test for flammable
Vessel/Workplace:
Others
Retest every
Hrs
Location:
Free from
flammable gas
Time
Task:
Weather condition:
Wind:
Knt
Work specification and drawings attached?
Sea state
Yes
Hand tools
Forklift
Dozer
Craft
Paint Gun
Electric machines/devices
Carpentary machine
Excavator
Tripod
Lathe machine
Rotating M/C
Others:
Free from
other toxic gas
Oxygen content
Ft.
No
Pressurized Air
Loader
Floating pontoon
Testing device
Cutting gear / Welding machin
Name:
Designation:
Signature
Date:
/
/
Discipline:
Lifting
Transport
Mechanical
Carpentary
Painting
Chipping
Sandfill
Construction
Blasting
Water jetting
Scaffolding
7. ISSUE
Area Authority:
Others:
Anticipated
commence:
Hrs
/
Date
/
Complete:
Hrs
Task requested by:
Designation:
Date:
Signature:
/
Date:
/
2. HAZARDS IDENTIFIED BY AREA AUTHORITIES
Danger From:
Liquid/gas under pressure
Naked flames/arcs
Tripping hazard
Flying particles/sparks
Corrosive materials
Radio active material
Flammable materials
Electricity
Hot surface
Moving machinery
Lifting operation
Cave in
Falling objects
Underground cables/pipelines
Static current (Sparks from rotating moving machinery)
I have personally checked the condition of the site. The necessary required action has been completed.
The work may proceed. All necessary precautions as indicated have been taken or shall be taken during
the execution of the job.
Name:
Designation:
Signed:
Date:
/
/
Time
Hrs.
Performing Authority:
Danger of falling in sea
Excavations
Confined space
Pyrophoric Scale
Sea state (vessel rolling/pting)
Traffic control
I have read and understood the above conditions and precautions and I declare that I accept
responsibility for carrying out the work specified on this permit, that no attempt will be made by myself or
by the men under my control to carry out any other work and that I will notify the Area Authority upon
completion / suspension of this work.
Name:
Designation:
Signed:
Date:
/
/
Time
Hrs.
thers:
Adjacent or Associated work:
8. COMPLETION / CANCELLATION
3. PRECAUTIONS TO BE TAKEN BY AREA AUTHORITIES
Performing Authority:
Thorough ventilation
Consider adjacent work
Isolation of area
Flushing with water
Suitable access and egress
Area free of flammable materials
Drains / sewers etc. within 15m of worksite sealed
Adequate supervision appointed
Earth of static electricity
Others:
I declare that the work for which this permit was issued has been properly performed, that all men have
been withdrawn, and that the equipment, plant and electrical apparatus affected by the work have been
left in a safe, clean condition.
The work is COMPLETE
The work is INCOMPLETE, abandoned / postponed due to:
Zone
Fire and Gas Detection inhibits:
Flame
H2S
Heat
Joint site inspection required prior to commencement?:
Yes
No
Affected area authorities consulted?:
Yes
No
Gas
(if yes, specify)
4. PRECAUTION TO BE TAKEN BY PERFORMING AUTHORITY
Standards / special procedures for this activity are identified and followed
Continous Gas monitoring
Adequate ilumination
Secure loose material / equipment
Proper housekeeping of work area
Work area properly baricaded
Warning signs Displyed
Job Safety Analysis (JSA) attached
Gauges are calibrated and certified
Equip. to be turned off and secured when left unattended
Lifting equipment tested & certified
Name:
Designation:
Signed:
Date:
/
/
Time
Hrs.
Area Authority:
I have inspected the equipment / work area and I declare that the work for which this permit was issued
has been properly performed, that all equipment have been removed, and that the equipment, plant and
electrical apparatus affected by the work have been left in a safe, clean, condition.
Fire extinguisher (specify type)
The work is COMPLETE
Others:
The work is INCOMPLETE and normal operations may be resumed subject to:
5. PROTECTIVE CLOTHING & SAFETY EQUIP. REQUIRED
Standard Coverall
Hearing protection
Walki talki
Life Line
Face shield
Safety Helmet
Dust mask
BA set
Work vest
Others:
Safety boot
Gloves
Inertia reel
Safety harness
PERMIT EXTENSION
From
Date
To
Time
Date
Time
/
/
Hrs.
/
/
Hrs.
/
/
Hrs.
/
/
Hrs.
/
/
Hrs.
/
/
Hrs.
Free from
Flam. Gas
Note: New Permit must be issued for any change in condition or cancellation
SITE GAS TEST
Free from
Toxic gas
Oxygen
content
Name:
Designation:
Signed:
Date:
Area Authority
Name
/
/
Time
Hrs.
REAVALIDATION SIGNATURES
Performing Authority
Signature
Name
Signature
Distribution: Original: Worksite;
Blue: Permit Authorizer;
Pink: HSED