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LIVE PERMIT TO WORK


WORK REQUEST No. -----------------
PTW No. ----------------
(A) ISSUE
1. Issued to -------------------------------------------- of ------------------ Valid until: ---------------------
2. Plant/Equipment work will be done ----------------------------------------------------------------------------
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3. Brief description of work to be done
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4. Safety Precautions to be taken:
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I hereby declare that I have checked the situation; it is safe to work on the above mentioned
plant/equipment in LIVE.

SIGNED: ---------------------------- Time: --------------------- Date: -------------------


Senior Authorized Person

(B) RECEIPT
I herby declare that I am thatisfied to work on above Mentioned plant/equipment in LIVE safely.

SIGNED: --------------------------- Time: -------------------- Date: -------------------


Authorized Person Maintenance

(D) CLEARANCE
I hereby declare that the work has been completed, all staff under my supervision have been
informed, tools and/or scaffolding removed, the work site has cleacred.

SIGNED ---------------- Time: ----------------- Date: -----------------------


Authorized Person Maintenance

(E) CANCELLATION
I hereby declare that the work site has been cleared and it is ready for service.

SIGNED: ------------------ Time: ---------------- Date: --------------------------


Senior Authorized Person

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