Work Permit

Company:
Date:
Project Title: Supply of Instrument Stanchion
Job Order: JO-18-215-YPI-042
Project Location: YPI Economia Road, Bagumbayan, Quezon City
Contact Reference: JAM
Permit Requester:
Description of Work: Fabrication of Stanchion

Location of Work:

Health & Safety Checklist: Before Start of Work YES NO N/A

1 Has a Work Procedure/JLA been produced specifically for the work?
Has a Risk Assessment/ Pre-Job Safety Briefing been carried out
2
specifically for this work?
Have persons been informed of the details of the Risk Assessment and
3
Work Procedure specific to this work?
Hot Work
Have combustible materials and flammable liquids or gases been
1
identified and removed from the area?
2 Are all equipment inspected before using?
3 Is the person trained and competent to use that equipment?
PPE such as safety glass, welding mask and clothes etc. are provided
4
and/or in good condition?
Is suitable fire-fighting equipment such as fire extinguisher in place and
5
persons able to use it?
6 Are there emergency procedures in area?
Other Specific Hazard:

Working at Heights

Is the person who is required to work at height been trained for this
1
type of work?

Is the person who is required to work at height suitably competent

2
and fit?
Has the equipment such as full body harness for working at height been
3
inspected by a competent person?
PPE such as safety glass, hard hat and gloves etc. are provided and/or
4
in good condition?
 5 Are there emergency rescue plan/procedures in area?
Other Specific Hazard:

Electrical Isolation/ LOTO

1 Is the power source has been identified and shutdown?
2 Test has been conducted/carried out to verify that no supply present?
3 LOTO has been attached to confirm isolation?
PPE such as safety glass, hard hat and gloves etc. are provided and/or
4
in good condition?
5 Are the tools properly insulated?
6 Are there emergency procedures in area?
Other Specific Hazard:

Permit Issuer: Permit Approver:

Date: Date: