Height Work Permit
Project:
Form No :001
PMC
Permit No :
Contractor
Date of issue :
PERMIT MUST BE TAKEN BEFORE STARTING THE WORK.
Permit Valid up to :
PERMIT MUST BE DISPLAYED AT SITE. ATTACH TOOL BOX TALK COPY WITH PERMIT.
Dept.
Note:
Contractor Safety officer :
Contractor execution engineer :
Contact (Extn) No :
Contact (Extn) No :
Area of work :
Please mark the location of work
Job description:
System(s) used during the works
Elevated work platform
(i.e. scissor lift)
Roof and/or ladder anchor points
Ropes and harness
Step ladder
Scaffold platform
Edge protection
Mobile scaffold
Safety net
Other (please specify):
Equipment Used :
CONTRACTOR’S COMPLIANCE STATEMENT
We hereby confirm that the following HSEQ requirements shall be complied with:
Yes
Remark
/No ( Give reason for No
/NA
option)
Statement Description
SN
1
Only medically fit personnel engaged in work and list is available.
2
Job Hazards is explained to all concern thru tool box talk meeting.
3
Ladder(s) inspected prior to use
4
Ladder properly supported and levelled (For access purpose only) and tied top and
bottom
5
Distance between the ladder support and the ladder base is at least ¼ the total length of
the ladder. Ladder been provided with skid resistant feet
6
Scaffolds/platforms inspected for good stability and proper construction (secured flooring
and guardrails) Floor openings covered / Guarded.
7
Has scaffold/boom lift/scissor lift working platform is loaded within safe working load.
8
Work area cordon off and warning signs in place. Proper Housekeeping is done.
9
Personnel assigned to warn of floor opening or other hazardous exposure.
10
Tools and other equipment stored in safe manner
11
Area cleared below prior to start work
12
Proper equipment provided
13
Safety Harness and Lanyard anchored to independent rigid object
14
Lifeline with rope grab shock absorber/fall arrestor
15
Full Body harness is used by all workmen engaged at height work.
16
Safety net is provided but not less than 5 M from the work area.
17
Electrical cable/ welding hose / compressed air hose properly secured and lay down
without obstruction.
18
Full Body harness and other PPE's are used by all workmen engaged at height work
Any Safety Remarks:
Night Work Precautions
19
General area & task Illumination is provided and secured properly
20
Emergency vehicle and driver available at standby
21
Non-compliance observed at work place to be closed prior commence of night work
22
Continues on job supervision to be available for the night works
* Contractor Supervisor to be in the workplace throughout the completion of the work.
Note: * To close the permit, concerned supervisor to check the workplace for any abnormalities after completion of the work.
* A separate permit to be filled for hot work if performed at height.
Permit requesting by Contractor
Name, Sign. & Time:
(Site Engineer)
Name, Sign. & Time:
(Safety Engineer)
Permit approved by PMC/CLIENT
Name, Sign. & Time:
(Site Engineer)
Name, Sign. & Time:
(Safety Engineer)
Permit Closed by
Name, Sign. & Time:
(Contr. Site Engg.)
Name, Sign. & Time:
(Contr. Safety Engg.)
Name, Sign. & Time:
(PMC Safety Engg.)