HSE DEPARTMENT
LIFTING PERMIT
PROJECT :
COMPANY :
LOCATION OF WORK :
DESCRIPTION OF WORK :
PERMIT VALIDITY PERIOD : HOURS:
ISSUED DATE:
TIME:
am/pm
This permit is valid for the day, time and periods stated above. The conditions of issue
must be complied with throughout the duration of the work. This permit may be
withdrawn at any time. You are responsible for the copy of this permit and must produce
it on request. This original approved permit to be given to the safety officer and a copy to
be displayed at the lifting area.
STAGE 1- PERMIT REQUESTER :
I have checked and confirmed that the following safety requirement have been complied with :
Valid Third party certificate available
Valid third party certificate available for
lifting gears
Competent lifting supervisor available
Access for crane is in good condition
Limit swiches are functioning properly
Sitting distance from excavation /
Trenches meter and roped off with
warning sign
Warning lights & horn are in good
condition
Ls &rigger / signal men with proper attire
Warning sign positioned
Competent crane operator available
Inspection checklist by crane operator &
lifting supervisor available
Lifting area cordoned off
Lifting machine is in good condition
Lifting gears are in good condition
Sitting distance from overhead electrical
cable -------------------mtr. Roped off with
warning sing
Tool box meeting & record
Risk assessment for lifting briefed
Out rigger and positioning the crane
STAGE -2 – ENDORSEMENT BY LIFTING SUPERVISOR/BANKSMAN
I have inspected the above- stated location and confirmed that the recommented
safety measures are in place and the said location is safe for work
NAME :
Designation :
Date/Time :
signature :
STAGE – 3 APPROVAL BY MEFG CONSTRUCTION MANAGER / ENGINEER
I am fully satisfied that a through inspections and proper assessment of the work area
and its surrounding have been made so that the lifting operation can be carried out
safety.
NAME :
Designation :
Date /Time :
Signature :
STAGE -4 CONFIRMATION BY SITE FOREMAN / OPERATOR
I have read the condition relatingto the work to be performed . I fully understand the nature
of work and the satety compliances.
NAME :
designation:
signature:
NAME:
designation:
signature