Ref No.: GPL F HS 23 Rev.No.

00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - EXCAVATION WORK

Permit Applicant : Name Of Contractor : Location:
(Person responsible for performance of the work)
Scope of Work: No. of Workmen:
Equipment/machineries involved:
Work Permit Validity :-

Permit Extension - Permit Applicant Work Release Authority

Issue Date________________________ & Time ___________________________
Expiry Date ______________________& Time ___________________________ Date / Time / Sign

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of
Date / Time / Sign
extensionrequired authorization as above is "MUST".
Date / Time / Sign
EXCAVATION WORK - Check Points
Exacation includes digging of pits, ditches, trenchetc… boring and drilling as well as driving of objects into soil.The activities shall be coordinated in such a manner that the exposure of
personel to hazards can be ruled out.
Sr. No Measure Remarks
TBT to workmen regarding hazards and working procedure conducted (Attach Attendance)
1 YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 Access ladder / Doka stair provided. YES NO N/A

4 Access ramp with not more than 15° gradient. YES NO N/A

5 Barrication & Signages provided. YES NO N/A

6 Excavation / digging area demarcated. YES NO N/A

Existance of underground utilities and overhead utilities checked. ( gass line, electrical cable,
7 YES NO N/A
water / sewer line, HT/LT lines etc…)
8 Danger to structures/ building in the proximity checked. YES NO N/A

9 Dewatering pumps available and working. YES NO N/A

10 Angle of repose/ bench cut/ slope provided and maitained as per soil strata. YES NO N/A

11 Shoring / Strutting provided.provided as recommended by consultant. YES NO N/A

12 Any leakage from near by water body, sewer line etc…. Checked. YES NO N/A

13 Relevant personal protective equipment available YES NO N/A

14 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Component to be Isolation List : YES NO
isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as property. I will
abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : ___________________________________________ Mobile No:__________________________

Date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action

Contractor EHS Engineer / Manager : - ______________________________________

Name / date/ time/signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/time/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/time/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by work release Work Completion Handover:
authority. PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of
Completion *In case of energy isolation, shall verify the completion of work, ask for and verify the
re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 24 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - HEIGHT WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance of the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of Date / Time / Sign
extension required authorization as above is "MUST".
HEIGHT WORK - Check Points
Any work on, below, or above ground level where there is risk of personal injury through falling and/or a potential risk to people below the work site being injured by falling
objects.s.

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted (Attach
1 Attendance) YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 Height pass issued to all the workers working at height. YES NO N/A

4 Personnel provided with full body harness, fall arrestor & life line. YES NO N/A

5 ladder and scaffold secured and supported propely. YES NO N/A

6 Weather condition normal and high wind pressure observed during the height work YES NO N/A
Working platform with full decking, double railing, access ladder, bracing, toe board,
7 YES NO N/A
base plate/wheel lock etc…. Provided.
8 Working area bellow safely barricaded. YES NO N/A

9 Are around the workplace cleared and all scraps removed after complition of work. YES NO N/A

10 All tools are fit and properly anchored and carried in bags / tool kit. YES NO N/A

11 Vertical and catch net provided below progress floor. YES NO N/A

12 Supervision available at the place at all time. YES NO N/A

13 Whether illumination of mim 50LUX maintained at the work location. YES NO N/A

14 YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as
property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : ________________________________________Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action

Contractor EHS Engineer / Manager : - ______________________________________

Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by work Work Completion Handover:
release authority.
Notification of PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 25 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - CONFINED SPACE WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..
(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of Date / Time / Sign
extension required authorization as above is "MUST".
CONFINED SPACE WORK - Check Points
A 'confined space' means any place, including any chamber,AC-ducts, lift shaft, tank, vat, silo, pit, trench, pipe, sewer, well, or other similar space in which by virtue of its
enclosed nature, there arises a foreseeable special risk. No person shall enter a confined space to do work unless it is not practical to achieve that purpose without entry.
Entry of confined space shall be subjected to the corresponding local statutory requirements and shall be released by an authorized person
following the implementation of special safety measure. work may not be started prior to issuance of a PTW to an authorized applicant having the responsibility for performing
the work.
Sr. No Measure Remarks
TBT to workmen regarding hazards and working procedure conducted (Attach
1 Attendance) YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 Escape routes to be provided and kept clear YES NO N/A

4 The vessel / equipment /Space been cleaned, purged, isolated YES NO N/A

5 All electrical / air/ hydraulic equipment / drives been disconnected and checked YES NO N/A

6 The gate watcher / constant supervisor at the place(gate) at all time. YES NO N/A

7 Rescue team equipped with emergency rescue devices like life line, ladder, rescue st YES NO N/A

8 24V hand lamp been provided YES NO N/A

9 Exhaust / fresh - air - flow fan been provided YES NO N/A

10 Tanks/ confined space well ventilated for about 6 - 7hrs before entry of person YES NO N/A

12 Any other Precautions taken:- ………………………………………………………………………………………………………………..

TEST REQUIRED:
S.No Gas Test Result Permissible Limit ( Without BA) Reading Remark Carried Out By Contractor EHS Coordinator
1 Exposivity 1% LEL
2 Carbon Monoxide (CO) 50ppm Max
3 Oxygen (O₂) 19.5 - 21 %
4 Carbon Dioxide 1200ppm Max
5 Others (H₂S) 10ppm Max
6 Temperature
Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline Equipments / Hand tools Fittness Fire Extinguisher Supervision
v
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement
Earthing Emergency Vehicle Weather Condition Medical Fitness
v v v
Other (Please Specify):
v
Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as
property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : ________________________________________ Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action

Contractor EHS Engineer / Manager : - ______________________________________

Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Work Completion Handover:

Physical verification of the closure of work is mandatory for sign off by
work release authority. PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of
Completion *In case of energy isolation, shall verify the completion of work, ask for
and verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 26 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - LOTO

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : __________________Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________

Name ( in block letters) / date/ signature Date / Time / Sign

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of Date / Time / Sign
extension required authorization as above is "MUST".
LOTO Process - Check Points
“Lockout” is the placement of a locking device on an energy isolation device, which assure that the equipment being controlled can’t be operated until the locking device has
been removed and “Tagout” is the placement of a tagging device on an energy isolation device...
These activities shall be coordinated in such a manner that the exposure of personnel to hazards or the impairment of plant safety can
be ruled out. It shall therefore be ensured that any unexpected or unplanned activation of equipment or energy shall not release during installation, maintenance, repair,
adjusting, unjamming, inspecting, operating, processing or construction process.

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted (Attach
1 Attendance) YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 All sources of energy are closed/disconnected from the equipment/process. YES NO N/A

4 Stored energy released before start of maintenance/repair. YES NO N/A

5 Interlocking devices/limit switches installed and functional. YES NO N/A

6 Lockout device/energy isolation device installed by authorized person. YES NO N/A

7 Tagout display placed on the enegy isolation device. YES NO N/A

8 All the sources of energy checked by authorized person for zero energy before start of
YES NO N/A
the activity.

9 Process of maintenance is as per approved methodology/user manual. YES NO N/A

10 All the controls are in place as per approved methodology/user manual.. YES NO N/A

11 All the personnel are competent to do the maintenance. YES NO N/A

12 Competent supervisor available throughout the maintenance work. YES NO N/A

12 Required PPEs available and in use for maintenance work. YES NO N/A

13 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as
(Application of permit property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
by Applicant)
Authorized Applicant of Contractor : _________________________________________Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action
(Applicants safety
engineer) Contractor EHS Engineer / Manager : - ______________________________________
Name / date/ signature

Authorized person ( Contractor)

Work Authorization
From Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Verified : Checklist / isolation action and specific EHS measures:
Authority __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by work Work Completion Handover:
release authority. PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 27 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - HOT WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : __________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of Date / Time / Sign
extension required authorization as above is "MUST".
Hot WORK - Check Points
Hot work are all activities in which welding, brazing,soldering, cutting, grinding, asphalt work etc… is performed directly on systems and/ or individual plant sections
containing combustible materials such as timber, cables, paints, plastics, packaging materials etc...
The activities shall be coordinated in such a manner that the exposure of personnel to hazards or the impairment of plant safety can
be ruled out. it shall therefore be ensured that any activities associated with the release of combustible substances, vapours, gases and liquids are not performed for the
duration set out in the hot work permit and in the area for which said hot work permit applies.

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted (Attach
1 Attendance) YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 All electrical connection checked & routed through 30mA ELCB YES NO N/A
Welding machine checked for fitness and gas cutting set for flash back arrestor and
4 YES NO N/A
NRV.
5 Wheel guard provided over rotating wheel & checked. YES NO N/A

6 Face shield, leather hand gloves provided. YES NO N/A

The area immediately below the work spot been cleared / removed of oil, grease &
7 YES NO N/A
waste cotton etc…
8 Combustible material to be removed / covered YES NO N/A

9 Tin sheet / wet gunny bags/ fire retardant cloth/ sheet provided to contain hot spatters
YES NO N/A
of welding / gas cutting.
10 Fire extinguisher, sand/water been kept handy at site. YES NO N/A

11 Water hose connection been made for continuous water spray, if required. YES NO N/A

12 Oxygen level and presence of other harmful gas checked in confined space. YES NO N/A

13 YES NO N/A

14 YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as
property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : _________________________________________ Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action

Contractor EHS Engineer / Manager : - ______________________________________

Name / date/ signature

Authorized person ( Contractor)

Work Authorization
From Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Verified : Checklist / isolation action and specific EHS measures:
Authority __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by work Work Completion Handover:
release authority.
Notification of PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 28 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - NIGHT WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..
(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of extension Date / Time / Sign
required authorization as above is "MUST".
NIGHT WORK - Check Points
Night Work: Night workers” means workers who usually work nights on rotating shifts schedules.

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted (Attach Attendance)
1 YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 All activities shall be carried out under proper supervision YES NO N/A

4 Workers are tired and unfit for work due to continues work. YES NO N/A

5 Illumination of min 50LUX maintained at the work place. YES NO N/A

6 Safety and legal local norms strictly followed.(Distrubance to local community ) YES NO N/A

7 Any unfavorable weather condition like heavy rain, wind / thunder. YES NO N/A

8 All electrically operated tools used with due care only by skilled workers. YES NO N/A

9 Separate work permit obtained for Hot work, Height Work, Excavation, and confined space e YES NO N/A

10 High visibility cloth provided and used by workers during night work YES NO N/A

11 Proper communication system in place to inform emergency situation to project manager / s YES NO N/A

12 All emergency No's displayed at site and known to night supervisor . YES NO N/A

13 Emergency vehical and first- aider with first-aid facility available at site during night work. YES NO N/A

14 YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as
(Application of permit by well as property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Applicant)
Authorized Applicant of Contractor : ___________________________________ Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure and Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
Isolation Action (Applicants
safety engineer)
Contractor EHS Engineer / Manager : - ______________________________________
Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)

Notification of Completion Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by Work Completion Handover:
work release authority.
PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of Completion
*In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 29 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - BLASTING WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Work Release
Permit Applicant Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of Date / Time / Sign
extension required authorization as above is "MUST".
BLASTING WORK - Check Points
Blasting: “blasting” means the cleaning, smoothing, roughening, cutting, preparation or removal of the surface or part of the surface of any building, ship or
article using an abrasive propelled or blasted against the building, ship or article by compressed air or steam, by a wheel or by any similar means, excluding
hydro-jetting;
Each abrasive blasting operation is unique, involving different surfaces, coatings, blast material, and working conditions. Before beginning work, employers
should identify the hazards and assign a knowledgeable person trained to recognize hazards and with the authority to quickly take corrective action to eliminate
them. Use engineering and administrative controls, personal protective equipment (PPE), including respiratory protection, and training to protect workers involved
in abrasive blasting activities.

A. Before Blasting
Sr. No Measure Remarks
TBT to workmen regarding hazards and working procedure conducted (Attach
1 Attendance) YES NO

2 Notification to other likely affected contractor / personnel. YES NO

3 Deployed only authorized license holder blaster. YES NO

4 Explosive have been stored in approved magazines. YES NO

5 Detonators checked individually for continuity & resistance YES NO

6 All detonators from same manufacturer. YES NO

7 Approved quality explosive and detonators used. YES NO

8 Lead / leg wires healthiness check. YES NO

9 Wooden tamping sticks used for stemming holes. YES NO

10 Personnel are taken to respective ' SHELTER ZONE' and area been cordoned off and al YES NO

11 Head counts matched after crosschecking with respective access controller YES NO

12 All electronic items/ radios, mobile phones, pagers electric power circuits and lights in t YES NO

13 Danger zone suitably cordoned and flagmen posted at important points. YES NO

14 Suitable warning boards displayed at site. YES NO

15 Blaster shelter available and in good condition YES NO

16 Ambulance / Emergency van kept ready. YES NO

17 Alert siren blown 3 times before blasting. YES NO

18 Local authority has been informed about the blasting time. YES NO

19 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

I have checked the above points and found conditions suitable to

Verified : Checklist / isolation action and specific EHS measures::
undertake the work:
Work Approval Permit Applicant( Site Eng./ Sup) : _______________________________ PMC/ GPL ( Area Incharge):-_____________________________
Name ( in block letters) / date/ signature Name ( in block letters) / date/ signature
B. After Blasting
Sr. No Measure Remarks

1 Weather any mis fire detected YES NO

2 Ensure respective shelter zone fan put 'ON' first YES NO

3 Remaining Explosive & Detonators are cleared from the area. YES NO

4 All clear siren / signal blown or conveyed. YES NO

5 Gas testing carried out & ensure the gas limits YES NO
 6 Aafter 5 minutes of blast, a careful inspection of the face is made by the expert to. YES NO

7 Explosive reconciliation records are maintained. YES NO

8 Send information to access controller after defuming is completed. YES NO

Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name &
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above
site as well as property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : _______________________________________Mobile No:____________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action

Contractor EHS Engineer / Manager : - ______________________________________

Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)

Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________

Notification of
Completion
( Respective site manager/ area incharge / Sr. Engineer):

( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by Work Completion Handover:
work release authority. PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

 PTW NO : …………….
Desired date & Time: from
Holiday Work Permit

List of Activities with respective locations:

Remark
Measure
YES
Communication / E-Mail information for working on Holiday sent on previous
1
day
2 Is Area Incharge available? Specify name of responsible person.
3 Is Safety Officer available? Specify name of Safety Officer.
4 Is safety resource as 1for every 100 worker or 1 for every tower available?
5 Is Ambulance Driver available? Specify name of Ambulance Driver.
6 Is First Aider available? Specify name of First Aider.
7 Is member of Fire fighting team available? Specify name of firefighter.
8 Is authorised Electrician available? Specify name of Electrician.
9 Is Tool Box Talk conducted? Specify name of TBT Conductor.
10 Are execution supervisors available at site?
Is there any task given in isolated area and required safety and supervission
11
measurd ensured
Is separate permit for other relevant activities, like height work, hot work etc…
12
taken
13 Instruction to Personnel regarding hazards and working procedure

14 Is weather condition normal?

Whether mandatory PPE like safety shoe, helmet, full body harness, fall
15
arresters are provided.
16 Is site barricading in place?
Whether all scraps are removed and area cleared for smooth operation before
17
start of work.
18 Any other Precautions taken:- …………………………………………………………………………………………

Tick As Applicable

Barricades, warning signs Helper / watcher Fall arrestor

Safety harness with lifeline tool kit Illumination

 Tools Fittness Scaffolders working Platform

Ventilation Method Statement Risk Assessment

Additional Safety Precaution / Remarks :-

I have checked the above points and found conditions suitable to

undertake the work:-
Permit Applicant
(Site Enng/ Sr. Sup):- Name ( in block l

Work Authorization From Authorized person ( Contractor)

Contractor ( Respective site manager/ area incharge): _________________________________
Name ( in block letters) / date

Check of EHS Measure

Contractor EHS Engineer / Manager : - _____________________________
Name ( in block letters) / date/ sig

Checklist / isolation action and system - specific EHS measures verified &
satisfactory:
Work Release Authority
PMC/ GPL Site management ( Site manager / area inchrage )

Work completed as specified :

Notification of Completion Applicant of Contractor : __________________________________
( Site Engineer/ Supervisor) Name & signature

Note :- We the undersigned, hereby confirm to perform the above mentioned work in compliance with the relevent le
practices, site rules and regulation, and GPL guidelines. Implemetation of above safety standards /precautions shal
the contractor performing the work. The site management of the GPL / PMC assumes no liability in this regard.
 PTW NO : ……………. Location: ……………….
Desired date & Time: from:_______ to________
t

Remark
NO NA Responsible Person

……………………………………………………………..

Fall arrestor Escape route + kept Clear

Illumination ladder
 working Platform Eye protection

Risk Assessment Others

___________________________________
g/ Sr. Sup):- Name ( in block letters) / date/ signature

_________________________________________
Name ( in block letters) / date/ signature

______________________________________
Name ( in block letters) / date/ signature

sures verified &

satisfactory:
_______________________________
ager / area inchrage ) Name ( in block letters) / date/ signature

Work Completion Handover:

PMC/ GPL : ________________________
Name & signature

compliance with the relevent legal requirements, industrial

ety standards /precautions shall be the sole responsibilty of
s no liability in this regard.
 Ref No.: GPL F HS 30 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Work - ELECTRICAL WORK

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of Date / Time / Sign
extension required authorization as above is "MUST".

Work Authorization Authorized person ( Contractor)

From Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________
Name ( in block letters) / date/ signature

I declare that apparatus / equipments mentioned above is safe to work and shutdown is given and the same will not be made alive till the permit is
cancelled in writing by the person taking shutdown.
LOTO / SHUT-DOWN
Person Issuing Shutdown (Electrical / P&M Incharge - Contractor ): ______________________________________________
Name ( in block letters) / date/ signature
Check of EHS :- Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoint for perticular catageory have been verified & satisfactory and allowed to
Measure and Isolation work.
Action
Contractor EHS Engineer / Manager : - ______________________________________
Name ( in block letters) / date/ signature

verified : Checklist / isolation action and specific EHS measures:

Work Release __________________________________________
Authority
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

ELECTRICAL WORK - Check Points

Electrical Work:

Sr. No Measure Remarks

TBT to workmen regarding hazards and working procedure conducted (Attach
1 Attendance) YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 Permission for the intended work been confirmed from project manager/ concern. YES NO N/A

4 Equipment isolated from all source of supply. YES NO N/A

5 Lockout device fixed at all point of isolation. YES NO N/A

6 Caution / danger Sign fixed at all points of isolation. YES NO N/A

7 Equipment / Electrical panel/DB's been proved dead by competant electritian. YES NO N/A

8 Safety lock fixed to secure temporary earth or Isolated. YES NO N/A

9 Where the work involves a cable has it been identified with certainty. YES NO N/A

10 Lockout key handed over to the responsible person. YES NO N/A

11 Working area has been barricaded/ isolated. YES NO N/A

12 Tagout or warning tag is secured onto the energy isolating point YES NO N/A

13 Mandatory PPE's like rubber gloves, elctrical safety shoes, emergency light etc provided. YES NO N/A

14 Duoble insulated / wooden handled tools used. YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Permit received:

I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as
Performance Of Work property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel

Authorized Applicant of Contractor : ____________________________________________

( Site Engineer/ Sr. Supervisor ) Name ( in block letters) / date/ time / signature
Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Physical verification of the closure of work is mandatory for sign off by work Work Completion Handover:
release authority.
Notification of PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 31 Rev.No.00
Date 10/20/2020 PTW NO:-…………….….

Permit To Open Manhole Cover / Cut -outs and lift shaft - Grills/ Handrails/ Safety Net/ Hard Brrication

Permit Applicant : - …………………………………………………….……………………………………………………………………..

(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-

Permit Applicant Work Release Authority

Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________
Date / Time / Sign
Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of extension Date / Time / Sign
required authorization as above is "MUST".

Open Manhole Cover / Cut -outs and lift shaft - Grills/ Handrails/ Safety Net/ Hard Brrication - Check Points
Activity : _______________________________________________

Date: _____________ From hrs ____________ to hrs. ___________

Permission required for temporarily removal Of :

Manhole Cover : Cut/out : Lift Shaft /ducts : Handrail: Safety Net: Hard Brrication:
Sr. No Measure Remarks
TBT to workmen regarding hazards and working procedure conducted (Attach Attendance)
1 YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 Separate routes for man and material entry to be provided and kept clear below Grill/
YES NO N/A
Guardrail which is to be removed.

4 Area below been fenced/ barricaded YES NO N/A

5 Caution signages, red light / reflectors/ red flags been displayed at the loaction ( Specially
YES NO N/A
at night)
6 Fall protection PPE provided ( Fall grab arrestor & safety net etc..) YES NO N/A
Installations like gas, electrical supply,water line, chemical line etc.. Disconnected in
7 YES NO N/A
existing structure.
8 Supervision available at the place at all time. YES NO N/A

9 Existing safety measures removed and install other appropriate measures at the time of
YES NO N/A
work.
10 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

To be filled in by Engineer-incharge / Site-in-charge permitting to open the manhole cover / grill /

handrails/safety net/ Hard barrication after ensuring that safety precautions have been made at the
proposed area for opening the cover.:- ____________________________________________________________
(Permitte / Site Eng/ Sr. Sup):- Name ( in block letters) / date/ signature

Additional Safety Precaution / Remarks :-

Component to be Isolation List : YES NO

isolated: If Yes - Special measure/requirements :
1. Energy to be isolated - Electrical/Mechanical/Hydraulic/Steam/Water/Other - Pls. Specify -
2. Method of Isolation -
X
3. Type & No. of LOTO device
4. Person responsible for Isolation - (Name & Sign) 5. If shift change, person responsible for Isolation - (Name & Sign)
Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as well as property.
(Application of permit by I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Applicant)
Authorized Applicant of Contractor : ________________________________________ Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure / isolation actions : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.
and Isolation Action
(Applicants safety
engineer) Contractor EHS Engineer / Manager : - ______________________________________
Name / date/ signature

Authorized person ( Contractor)

Work Authorization From
Contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Additional Safety Precaution / Remarks :-

Work Release Authority Verified : Checklist / isolation action and specific EHS measures: __________________________________________
PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified : *Isolation device removed & re-energization done: (Yes/No/NA)
Notification of
Applicant of Contractor : _______________________________________ Person responsible for Isolation : ______________________________
Completion
( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature Name ( in block letters) / date / time / signature

Work Completion Handover:

Physical verification of the closure of work is mandatory for sign off by work
release authority. PMC/ GPL ( Site Manager/ Area Incharge): ________________________
Notification of
Completion *In case of energy isolation, shall verify the completion of work, ask for and
verify the re-energisation and sign off the permit after re-energisation. Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.
 Ref No.: GPL F HS 32 Rev.No.00

Date 10/20/2020 PTW NO:-…………….….

Permit To Work - GENERAL

Permit Applicant : - …………………………………………………….……………………………………………………………………..
(Person Responsible For Performance 0f the Work (Name, & Company)

Name Of Contractor :-…………………………………………………………………………………..………………………………………….

Type and Scope of work:-…………………………………………………………………...…………………………………………………….
Work Permit Validity :-
Permit Applicant Work Release Authority
Desired Date & Time : ___________________ Date & Time Of Expiry: __________________ Permit Extension -

Date / Time / Sign

Applicant : ____________________________________________________________

Name ( in block letters) / date/ signature

Note: In general maximum validity of a work permit shall not be exceed 1 (one) day. However in case of extension
required authorization as above is "MUST".
GENERAL WORK - Check Points
GENERAL Work: General work” means any work which is to be performed under controlled supervision and not included in PTW SOP.
Sr. No Measure Remarks
TBT to workmen regarding hazards and working procedure conducted (Attach Attendance)
1 YES NO N/A

2 Notification to other likely affected contractor / personnel. YES NO N/A

3 All activities shall be carried out under proper supervision YES NO N/A

4 Workers are fit to work and medically screened. YES NO N/A

5 Illumination of min 50LUX maintained at the work place. YES NO N/A

6 Safety and legal local norms strictly followed.(Distrubance to local community ) YES NO N/A

7 Any unfavorable weather condition like heavy rain, wind / thunder. YES NO N/A

8 All electrically operated tools used with due care only by skilled workers with appropriate
YES NO N/A
PPEs.
9 Separate work permit obtained for Hot work, Height Work, Excavation, and confined space et YES NO N/A

10 High visibility cloth provided and used by workers during night work YES NO N/A

11 Proper communication system in place to inform emergency situation to project manager / s YES NO N/A

12 All emergency No's displayed at site and known to night supervisor . YES NO N/A

13 Emergency vehical and first- aider with first-aid facility available at site during night work. YES NO N/A

14 Mandatory and job specific PPEs are issued and usage ensured. YES NO N/A

15 Any other Precautions taken:- ………………………………………………………………………………………………………………..

Tick As Applicable
Barricades, warning signs v Banksman / Flag man/ Helper Illumination Escape route + kept Clear
Safety harness with lifeline v Equipments / Hand tools Fittness Fire Extinguisher Supervision
Eye protection Competent Operator Respirators / Gas mask Risk Assessment
PPE's v Ventilation First - Aid Method Statement

v Earthing v Emergency Vehicle v Weather Condition Medical Fitness

v Other (Please Specify):

Additional Safety Precaution / Remarks :-

Performance Of Work I confirm that I have been given charge of the above mentioned work and I will take all necessary precaution to avoid danger to the workers engaged at the above site as
well as property. I will abide by the recommendations of the safety engineer and implement them and will assign jobs to only trained personel
Authorized Applicant of Contractor : ___________________________________ Mobile No:__________________________

Name/. / date/ time / signature

Check of EHS Measure Identified EHS measure : The precaution and safe condition mentioned in checkpoints have been verified & satisfactory and allowed to work.

Contractor EHS Engineer / Manager : - ______________________________________

Name / date/ signature

Authorized person ( Contractor)

Work Authorization /releasing
authority from contractor ( Respective site manager/ area incharge / Sr. Engineer): _______________________________________________ Mobile No:__________________________
Name / date/ signature

Work location visited and controls checked.Provide comments if required.

Work Monitoring Authority __________________________________________

PMC/ GPL Site Team ( Site manager / area inchrage ) Name ( in block letters) / date/ signature

Work completed as specified :

Notification of Completion Applicant of Contractor : _______________________________________

( Site Engineer/ Supervisor) Name ( in block letters) / date / time / signature

Intimation to PMC/GPL for Work Completion Handover:

Notification of Completion
Informed about the closure of the work to PMC/GPL and details eneterd in PMC/ GPL ( Site Manager/ Area Incharge): ________________________
the PTW register.

Name ( in block letters) / date / time / signature

Note:- :- to be completed by GPL / PMC site Representative

:- to be completed by contractor representative.

X :- only required for isolation; like underground public/ private utilities , overhead - underground HT/ LT electric supply lines etc…

:- GPL / PMC Safety engineer is authorized to visit and cross check safety measure at permit locations and in case of non-adherance, can STOP the work.