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    LTR Work Permit for Working at Height (1)

    Uploaded by

    mgupta0080
    Hight work permit

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    LTR Work Permit for Working at Height (1)

    Uploaded by

    mgupta0080
    1 views2 pages
    Hight work permit

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Hight work permit

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1 views2 pages

    LTR Work Permit for Working at Height (1)

    Uploaded by

    mgupta0080
    Hight work permit

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Work Permit For

    Working At Height

    Permit No__________ (Asper Permit Register) Date:___________________


    Note: MSRA is mandatory for this work permit. It should be attached with this work permit.

    Validity from: (Time) to (Date)


    Section I: Work Details
    Work Location:
    Expected Height of work from Ground
    Duration of work
    Details of Work to be carried out
    Supervisor / Engineer available full time? Name:
    Contact
    No:
    Drinking water& toilet available?
    Mention Nearer Location:
    Name of the Contractor and Nos. Contractor 1.
    personnel Carrying this work 2.
    All workers are passed vertigo test?
    Section II: To carry out work YES N N Section II: To carry out work YES N N
    O R O R
    1. Safe Access Provided? 2. Scaffold/Working
    Platform/ Ladder
    inspected & approved?
    3. Toolbox talk conducted?
    Name:
    4. Appropriate safety PPE
    5. Safety Harness worn? 6. Barricading to Working Platform?
    7. Lifeline provided 8. Area Barricaded?
    9. Vertical and Horizontal 10. Handrail/Mid-rail to
    Safety Net/ screen Provided? Working Platform?
    11. Electrical Isolation? 12. Toe board to working platform?
    13. Additional PPE Provided? 14. Warning signs?
    15. Working platform 16. Hand tools safely secured
    provided & inspected? for fall?
    Any other Safety measures required /suggested?

    Section III: Initiator of Work Permit


    I request for working at height permit for the above-mentioned work at the location specified above.
    I have personally inspected the workplace to ensure that the precautions mentioned above have been
    complied with.

    Date: Time: Name & Signature:


    (Contractor Section in-charge)
    Work Permit For
    Working At Height

    Section IV: Issuer of Work Permit


    I certify that the work location as specified above has been inspected and all the recommended safety
    measures have been taken. Subject to the said precautions being taken, the work can proceed.
    The permit is valid up to (Time) (Date)
    Name & Signature:
    (Contractor HSE In Charge)
    Section V: Inspection of Work Permit by LTR Area In-charge.
    The workplace has been inspected and allowed for work.

    Name & Signature:


    (LTR Area in-charge)
    Date & Time:
    Section VI: Inspection of Work Permit by EHS Dept.
    The workplace has been inspected randomly by LTR EHS safety dept.

    Name & Signature:


    (Project LTR EHS DEPT.)
    Date & Time:
    Section V: Cancelation of Work Permit
    This permit is hereby cancelled.

    Name & Signature: Name & Signature:


    (Contractor Section in-charge) (Contractor HSE In-Charge)
    Date & Time: Date & Time:

    Reason for cancellation of permit:

    Section VI: Renewal / Closure of Work Permit: (Tick as applicable)


    The work detailed in work permit has not been completed and renewal of permit requested for an
    additional period from (time) to (Date) ………………………….
    The work detailed in work permit has been completed and all equipment and personnel have been
    withdrawn from the area.
    The work detailed in work permit has been completed with proper Housekeeping and material
    stacking.

    Name & Signature: Name & Signature:


    (Contractor Section in-charge) (Contractor HSE In-Charge)
    Note: -
    1. Ensure all labor’s/men’s working at height are trained for the same & toolbox training is
    Conducted prior to work.
    2. "Understand work - Ensure Safety" before commencing work.
    3. Ensure issues for works on the periphery are noted & adequate measures are taken!
    4. For continuation of permit, pl. notify authorized person at least 1 hr. before expiry of permit

     Abbreviation (MSRA): Method Statement & Risk Assessment.

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