HOT WORK PERMIT HWP No.

:
Planned Duration Planned Time No: of Workers: Fire Watch required: YES N/A

SECTION-7
Issued Date
Hrs From Hrs.To Hrs.
Work order/notification Details Name Authorization No. Signature Date

(Issuer)
Fire watch
Details of work activity:

SECTION-1
(Receiver)
Fire watch
Equipment details Work execution details

SECTION-9 SECTION-
(Issuer) (Issuer)
Dept./Plant Unit Name / No. Equipment Name/Tag No. Department / Contractor SOP/SMP IF# Fire protection: YES N/A
Barricade / barrier Fire blanket

8
Fire extinguish Cover drains&Catch Basin (withi
Description of work: Fire hose & noz Warning signs Spill containment Other _______
Affected Area Counter Sign by manager or above: Yes N/A
confirmation with comments:
Associated work permit / Certification: YES N/A Plant _____________ Name _____________________ Signature _______________ Date _________ Time __________
SECTION-3 SECTION-
(Issuer)

If YES, write applicable permits / certificates serial numbers below Plant _____________ Name _____________________ Signature _______________ Date _________ Time __________
2

LOTO/Eq. Excavation Vehicle Movement Lifting Confined space Entry permit Gas Test: YES N/A Frequency _____ Continuous Gas Test Device ID:

(Issuer/ Gas Tester)

Oxygen LEL CO CO2 Benzene H2S
Auth.
Time Name Signature

SECTION-10
Tools & Equipment to be uYES Ensure that all tools & equipment should b (19.5-20.8)% 0 (Max 10%) 25 PPM 5000 PPM 0.5 PPM 1.0 PPM PPM No.
(Receiver)

Hand tools Gas torch Soldering tool Fork lift

Electric tools Welding machine Grinder Crane
Pneumatic tools Generator/compressor Hydro-jetting machine Manlift
Hydraulic tools Grit Blaster Non-classified Electric ToolOther___
Hazards Identification check YES N/A
Flammable gas O2 Deficient atmosphere Trapped gas/ liqu Slip/Trip Authorization (After joint site visit )
SECTION-4

Toxic gas/fumes Dust/Fibres/Catalys Corrosive chemica Electrical Time Issued: From: To:
(Issuer)

(Issuer/Receiver)
Volatile liquid Heat stress Frost-bite Radiation Permit Issuer Permit Receiver

SECTION-11
High pressure Steam/Condensate Carcinogenic Finger trap I have checked & certify that the conditions &
I hereby accept the stated conditions & precautions for the work to be
precautions required are as stated & work can be
done safely and perform SECTION 14 &15 before starting the job
High temperatur Fall Hazard Rotating equipmen Flying Object carried out safely

High Noise Vibration Sharp Edge Organic

IIlumination Other __________ Other __________ Other __________
Special PPE required: YES N/A Name ________________ ID: Name _____________ ID:
Chemical Air line
SECTION-5

gloves Goggles Ear protection breathing set Authorization No.___________ Tel No: Authorization No. ___________ Tel No:
(Issuer)

Welding gloves Face shield Chemical suit Life line Signature ____________________________________ Signature___________________________________
Extension Endorsement

(Issuer & Receiver)

High voltage gl Dust mask Full body harness Footwear
Thermal Gloves Half/Fullmask respir SCBA Rubber boots I hereby accept the stated conditions & precautions
I have checked & certify that the conditions & precautions required
SECTION-12
Arc Flash for the work to be done safely and perform SECTION
are as stated & work can be carried out safely
Coated Gloves Hot Sticks Welding shield #15
Resistant
Leather Gloves Other ___________ Other ___________ Other __________ Permit Receiver: Permit Issuer
Tel Auth. Duration
Name Auth. No. Sign Time Name Signature Tel No:
Preparation check list, mention any abnormality or additional precau No: No. From To

Description YES NO N/A

1. Work area clean & free from combustible materials? Permit close-out
2. Manholes, catch pits/basins, sewer connections are covered? Permit Receiver:
RECEIVER

3. Process vents & manhole vents direct away from work site? Work is completed YES NO
SECTION-13

4. Radiation source is removed / locked? If, work is not completed, state reason _______________________________________________________________
SECTION-6

5. Toxic / flammable materials within 15 m radius of work area re

(Issuer)

Housekeeping completed YES

6. Work area barricaded, Signboard and Fence? Name _________________ Auth. Signatu Date _________ Time _______
7. Comply with SHEM-07.08 SHE critical devices.Counsel Sign: Acceptance by Permit Issuer:
8. Proper grounding in place to avoid static electricity? Confirm Work & housekeeping are completed,notify effected area i YES N/A
ISSUER

9. Will this work affect operations or other maintenance jobs wi Confirm all associated work permits / Certifications are closed YES NO N/A
10. Will this work affect DCS or PLC, if yes mitigation plan to b Name _________________ Auth. Signatu Date _________ Time _______
11. Equip de-energized line isolated drained depressurized purged&tagged? 1) Tick ( √ ) for applicable boxes in the permit
12. Ensure grating ,guardrail in place & secured properly. 2) Perform TAKE TWO before starting the job
NOTE

13. Ensure tools and equipment are inspected by user . 3) 2nd copy to be displayed at worksite until close-out and then exchange the copy with permit issuer
14. Ensure never place out triggers of crane over the gratings or
15. Welding Activity ,if yes fill checklist SHEM-08.10F.
 No Job Steps Potential Hazards Mitigation Plan Responsibility

(Receiver)
SECTION#14 JSA

For: Standard Non Standard (Use additional sheet if necessary as attached)

Is JSA approved by Team JSA Number#

Agreement for execution that I understand the criticality of task and all hazards related to job steps. I am expected & obligated to take all measures in job
step hazards control to mitigate risk level associated with this task.
Receiver: Supervisor: Name: Badge No: Signature:

TAKE TWO: Take two minutes to think through a job before the job is started.
Gas Test Results
Oxygen LEL CO CO2 Benzene H2S * Is the access / egress and lighting adequate? YES No
Auth.
Time Name No. Signature
(19.5-20.8)% 0 (Max 10%) 25 PPM 5000 PPM 0.5 PPM 1.0 PPM PPM * Is the task safe to do in today's weather conditions? YES No

* Are you aware of, and do you have the correct PPE? YES No
SECTION#15 (GAS Tester/ Receiver)

* Do you have the right tools, and are they in good conditionsYES No

* Do all team members have a full understanding of the task? YES No

* Is the work area free from conflicting activities? YES No

* Are Manual call point, assembly area point & safety shower kYES No

If you answer NO to any of the above questions, then mitigation action should be taken
BEFORE starting work.

To be signed by crew members at the field just before starting the job.
ID #
Signature