LIFTING AND SHIFTING OF EQUIPMENT AND HEAVY

OBJECTS PERMIT

Unit: Department: Page: X of Y

W.P.No: L&S……...
On hearing Emergency Siren stop work in safe condition and assemble at Assembly Site Emergency Contact Nos.
point.

Permit Details

Permit From : Date: Time :

Validity
To : Date: Time :
Equipment
Other Permits
No / Tag
No:
ID :
First Aider Details ( available in
Emergency Dial no’s
shift)

Zone No: Exact Location :

1. ACTIVITY

Description of the Work :

Name of the Qualified and/or authorized Electrical Workers

Name of the Standby Person: …………………………… Sign: …………………………….

Name of the Contractor :
Name of the Co- Permitte : …………………………… Sign: …………………………….
Cell No : ………………………........
Tools and tackles to be used:

Name of the tool/ Tackle Identification No Date of Test certificate validity

2. PRECAUTIONS TO BE TAKEN

I PRECAUTIONS TO BE TAKEN BEFORE STARTING WORK YES NO NA

Is the lifting zone cordoned off adequately, to prevent access by
1.
unauthorized personnel?
Is appropriate caution sign board prominently displayed at the site of
2.
operation?

Copy 1 - ACCEPTOR Copy 2 - ISSUER Copy 3 - SHE

 LIFTING AND SHIFTING OF EQUIPMENT AND HEAVY
OBJECTS PERMIT

Unit: Department: Page: X of Y

3. Is the area clear of over-head electrical lines?
Third party inspection certificates available for all tools &
4.
equipment’s.
The system to be isolated and proved dead as per LOTO procedure
(Tick √ applicable)
Electrical Hydraulic Mechanical
5.
Compressed air Steam Other Pressure gases
Hot water/ Gases
Specify any other Energy presence
Is the Safe Work Load marked on the equipment?
6.
Name of Equipment:____________ SWL: __________________
Are the PUC Certificate and Vehicle Fitness Certificate from RTO,
7.
available?
Has the lifting equipment been examined at least once in the last 12
8. months by an authorized examiner ( third party) and does it posses a
valid lifting equipment certificate ?
Is the driver competent to handle the equipment? Does he have the
9.
license for Heavy Transport Vehicle?
Has the actual weight of the load being handled, established and
10.
within the Safe Work Load of the equipment ? Wt. of load: ______
Is the hook of the equipment in good condition and has been
11.
provided with a locking latch?
12. Is the Load Test Certificate of the hook available?
Is the load likely to clash with other structures or equipment along
13.
its lifting path?
14. Is a tag line provided to control movement of the load?
Has a safe means of access or egress been provided for personnel to
15.
attach or recover the rigging of the load?
Has the area been surveyed to identify the presence of potential
16
hazards?
17. Soil is compacted and suitable for movement of Cranes

II PRECAUTIONS TO BE TAKEN DURING WORK YES NO NA

1. Access to the work area to be restricted
2. All workers to wear required PPE
3. No personal movements below the suspended loads
4. Tag lines are in place
5. Cranes are in perfect position on firm ground
6. Qualified signal man for signaling
Contract supervisor present at the job site till the time the job is
7.
completed.

Copy 1 - ACCEPTOR Copy 2 - ISSUER Copy 3 - SHE

 LIFTING AND SHIFTING OF EQUIPMENT AND HEAVY
OBJECTS PERMIT

Unit: Department: Page: X of Y

III PRECAUTIONS TO BE TAKEN AFTER WORK YES NO NA

1. The lifting tackles are removed from work area
2. Ensure the load is perfectly or completely loaded/unloaded/erected

3. MANDATORY PPE &JOB SPECIFIC PPE (Tick √ applicable)

Mandatory PPE Helmet Safety Shoes Goggles

Ear Muff Hand Gloves Fall arrestor

Job Specific PPE Jacket with radium sticker Breathing Apparatus
Full Body harness with double hook

4. SUPPORTING DOCUMENTS (Tick √ applicable)

Supporting Documents ( tick √ applicable)

Drawings Tool box talk Record
Job Safety Analysis/ HIRA Standard Operating Procedure
Method Statement
Detailed job plan
Job Specific Supporting Documents ( tick √ applicable)
Test Certificates Qualification Certificates
Shift Plan Shifting Checklist
Lift Plan Lifting/ Erection Checklist
Load Chart Emergency Procedure
Others Specify: ……………….
5A. CUSTODIAN’S REVIEW
Remark if any by Custodian :

Name (Custodian): ………………………… Sign: ………………… Date:………….. Time: ………

Name of issuer Nominated by Custodian: …………………………………………….

5B. ISOLATION DETAILS

Details of lock and tag Nos Released of energy Name of isolator/ Signature
Isolation Done and try out Area owner
performed Y / N
         
         
         
         
Issuer’s declaration:
“I have inspected the equipment / work area and declare that the isolations mentioned above
are completed by authorized isolators permit”

Copy 1 - ACCEPTOR Copy 2 - ISSUER Copy 3 - SHE

 LIFTING AND SHIFTING OF EQUIPMENT AND HEAVY
OBJECTS PERMIT

Unit: Department: Page: X of Y

Name (Issuer): ………………………… Sign: ………………… Date:………….. Time: ………
6. AUTHORIZATION AND ACCEPATNCE

SHE review & comments(Work must be initiated after SHE Clearance only)

……………………………………………………………………………………………………………..

Name (SHE officer): ………………………… Sign: ………………… Date:………….. Time: …..

Initiator and Co Permittee (Contractor & Work Engineer)

"This certifies the successive steps of the work, the potential hazards and the safety precautions
have been explained and understood. The requested trainings were performed".

Name of acceptor: ……………………… Sign: ………………… Date:………….. Time: ………

Name (Initator) : ……………………… Sign: ………………… .Date:………….. Time: ………
Issuing Authority
"This certifies that I have consulted all relevant dept./personal, discussed the scope of work, inspected the
preparatory work and the work area covered by this Work Permit. I therefore confirm that the work can be
carried out".
Name (Issuer) : ……………………………. Sign: ………………… Date:………….. Time: ………

7. PERMIT VALIDATION IN CASE OF CHANGE IN PERSONNEL / EXTENSION OF PERMIT

Is there any change in personnel in PTW issued? If yes fill below information
Changed Names of the people involved:

We hereby request you to endorse new personnel in permit/ extend the permit for ……… time to ……….
Time
Co-permittee Name & Sign : Initiator Name & sign :

SHE review & comments

……………………………………………………………………………………………………………..
……………………………………………………………………………………..

Name (SHE officer): ………………………… Sign: ………………… Date:………….. Time: ………

Acceptance of the recommendations

Name (Co-Permittee): ………………………… Sign: …………… Date:………….. Time: …………

/ Acceptor)
Name (DRL Initiator): ………………………… Sign: …………… Date:………….. Time: …………
Name (Custodian ) : ………………………… Sign: …………… Date:………….. Time: …………
Issuing Authority

Copy 1 - ACCEPTOR Copy 2 - ISSUER Copy 3 - SHE

 LIFTING AND SHIFTING OF EQUIPMENT AND HEAVY
OBJECTS PERMIT

Unit: Department: Page: X of Y

"This certifies that I have consulted all relevant dept./personal, discussed the pending work,
inspected the work area covered by this Work Permit. I therefore confirm that the work can be
carried out permitting endorsement of (new/ changed ) personnel as above / Extension of permit ".
( Strike off which is not applicable)
Name (Issuer) : ……………………………. Sign: ………………… Date:………….. Time: ………

8. WORK COMPLETION / CANCELLATION

Initiator (Work Engineer) :
"I declare that the work has been properly performed that all the men have been withdrawn, Energies
are Restored and safe the equipment and electrical apparatus affected by the work have been left in a
safe, clean condition".
Name (Co-Permittee): ………………………… Sign: …………… Date:………….. Time: …………
/ Acceptor)
Name (DRL Initiator): ………………………… Sign: …………… Date:………….. Time: …………

Equipment No. Restoration of Removal of Lock and Name of isolator/ Signature

energies tags Custodian

       
       
       
       

Name (Custodian) : ………………………… Sign: …………… Date:………….. Time: …………

Issuing Authority
“I have inspected the equipment / work area and declare that the work for which this permit was
issued has been properly performed, that all tools and apparatus have been removed, energies are
safely restored and the equipment and electrical apparatus affected by the work has been left in a
safe, clean condition"

Name (Issuer): ……………………………. Sign: ………………… Date:………….. Time: ………

Copy 1 - ACCEPTOR Copy 2 - ISSUER Copy 3 - SHE