LIVE ELECTRICAL WORK PERMIT
1. Project Information: (To be filled by initiator/originator)
Project Name:
Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Location / Area :
Panel No :
Voltage:
Permit Validity:
Time (from): _______Hrs.
Time (To): __________Hrs.
Date:
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
No:
Checks
Yes-No-NA
Checks
ENERGIZATION (“Power On”)
ISOLATION (“Power Off”)
1.
Safety tool box briefing done.
☐ ☐ ☐
2.
Authorized personnel /
operators available.
Method statement/Risk
assessment in place.
Safety Barriers in place and
safety signage Displayed.
Working area is well lighted.
☐ ☐ ☐
6.
Electrical instruments are
available for any Purpose.
☐ ☐ ☐
7.
Correct PPE available, high
voltage rubber Gloves, safety
goggles and floor mat.
Approved WIR for installation,
testing and Termination are
attached to the permit.
Emergency light (Flashlight)
available.
Is live work absolutely
necessary?
☐ ☐ ☐
Unauthorized workers are
cleared from the area.
3.
4.
5.
8.
9.
10.
11.
Page 1 of 2
Yes-No-NA
☐ ☐ ☐
☐ ☐ ☐
☐ ☐ ☐
Method statement/Risk assessment in
place.
Authorized personnel / operators
available.
Adjacent live areas protected.
PPE available, high voltage rubber
gloves, Safety goggles and floor mat.
Isolation/Lock-out in place.
☐ ☐ ☐
☐ ☐ ☐
☐ ☐ ☐
☐ ☐ ☐
☐ ☐ ☐
Electrical circuits “proved” by
calibrated Instrument and found out to
be no power.
Unauthorized workers are cleared
from the Area.
☐ ☐ ☐
☐ ☐ ☐
Standby operatives in the event of
contact With live circuits.
☐ ☐ ☐
☐ ☐ ☐
Emergency light (Flashlight) available.
☐ ☐ ☐
☐ ☐ ☐
Emergency response plan available
☐ ☐ ☐
☐ ☐ ☐
Other ( Specify):
☒ ☐ ☐
☐ ☐ ☐
Form # HSEQ- LEP (Rev 2 Mar 23)
LIVE ELECTRICAL WORK PERMIT
12.
13
14
Power cable route from panel
board to plant & equipment has
been checked
Emergency response plan
available
☐ ☐ ☐
Other ( Specify):
☐ ☐ ☐
☐ ☐ ☐
4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives,
and I consider them competent to do it safely.
Initiator/Originator
Designation:
Name:
Signature:
Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team):
Designation:
Signature:
Date /Time
Comments (if any):
5. Authorization (PM/CM):
Name:
Designation:
Signature:
Date /Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature:
Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature:
Page 2 of 2
Time:
Form # HSEQ- LEP (Rev 2 Mar 23)