Annexure – 1A

PERMIT TO WORK FOR INDIVIDUAL WORKING AGENCY

[TO BE FILLED IN TRIPLICATE BY PARTY – ORIGINAL YELLOW & OTHERS WHITE]; VALID FOR ONE SHIFT AND MAY BE RENEWED TWICE ONLY)
Sl. No: ……………… Date: ……………………………….
Location Site …….………………………………………… Area # ………………………………………………. SECTION: …………………………………….
Original permit Validity (Date and Time) From: ……………………………………………………. To: …….……..…..………………………………….
1st Renewal Validity (Date and Time) From: ……………………………………………………. To: …….……..…..………………………………….
2nd Renewal Validity (Date and Time) From: ……………………………………………………. To: …….……..…..………………………………….
SHUT DOWN TAKEN: YES NO NA (IF YES), SHUT DOWN planned From:……………………….. To:……………………….
Details of job to be undertaken
1. Area/ Tank/ Vessel/ Equipment/ Pipeline Exact Location: Equipment #:
2. Work to be done: Working Agency; No. of Manpower:
Engineer/Supervisor:
Work Order / Service Order #
3. Safety Precautions
a Breathing Apparatus / Gas sets (as applicable)
b Protective Equipments to be worn (Ring items which apply):
Helmet, Eye Wear, Face Shield, Self-Contained Breathing Apparatus, Supplied air mask, Ear Muffs, Fire Retardant Cloths, Hand Gloves,
Shoes, Gumboots, High Visibility Jacket, Full body harness, Electrical flash suits Any others:
c Area Clearance taken from the owner department :(YES/NO/NA)
Other Precautions / Special Instruction:
4 State of Isolation No. of lines Depressurized Positive Tagged Valve Initials as Not
(Electrical, Solid, Gas, Vapor, Fuel, Solid, & Drained Isolation Off Only applicable Isolated
Air, Nitrogen)

5 All Motive Power has been isolated and any YES Lock #
logic control interrupted (LOCK/ TAG) NO Tag #
6 Electrical fuses have been withdrawn & all
circuits are dead & Try Out Process Followed Sign …………………………. (EAP) Name …………………………………………….Date……………… Time………………

7 Electrical circuits are live for trouble shooting

only (control power): Sign…………………….. (EAP) Name…………………………………………….. Date……………… Time………………
8 CONFINED SPACE ENTRY Oxygen Level O2 % :
(Cancelled if not required) System Isolated : (YES / NO / NA)
Rescue System : (YES / NO / NA)
CS Number : _______________________ CS Attendant : (YES / NO / NA) Name: ………………………………
Location : _______________________ Register for Entry & Exit: (YES / NO / NA)
Any Other Gas ………….ppm and is therefore safe to enter from ………….Hrs. to …………….Hrs.
Warning Sign : Yes / No on date…………….. Signature (Approved Signatory)……………………………….
9 HOT WORK / OTHER HAZARDOUS WORK (Working at height, Pneumatic / Hydraulic System, Material Lifting, Excavation,): Inspected the
site as per requirement overleaf, Job Specific HIRA/SOP exists (Doc# ………………………………………………………………………..) and JSA enclosed (Yes / No)

10. I understand the hazard involved and have taken all necessary precautions/controls as mentioned above.
Permit Original Permit Renewal First Permit Renewal Second
Requested by Issued by Taken by Issued by Taken by Issued by Taken by
Name / G / EPN

Designation / Dept.

Signature

Date & Time

11. Return of Permit: - After completion of job, removal of all materials / men from site has done by Working Agency. Now Equipment & Area is
safe for operation. The above Equipment / Facility can be restored.
12. Request by OAP to EAP for Power
Permit Return by MAP Permit Received by OAP
Restoration after completion of Work
Original 1st Renewal 2nd Renewal Original 1st Renewal 2nd Renewal Signature of OAP Date Time
Name / G / EPN
Designation /
Dept. Power Restored by the EAP
Signature
Signature of EAP Date Time
Date & Time
NOTE: This PTW shall deemed to be cancelled if there is any change in work condition, climate (rain, storm) & team working.
*(Synonyms of term used : Initiator / Requestor – MAP; Issuer – OAP, , Authorized isolator – EAP, Co-permittee / Taken by – Authorized by MAP, Receiver - verifier)

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 Annexure – 1A
Checklist to ensure Safety (Multiple categories may apply to any given job):- Check items completed prior to start.

1. Permit to be issued by people not less than Site Engineer (from Adani Business Location/Contractor’s).
2. Permit receiver may be party who raised work order to frontline working agency, issuer may be party owning site and receiver may be the working agency or agency who had awarded work
order for the specific job.
3. This work permit cannot be raised unless SWP /SOP/ JSA is available and site induction / tool box talk is given based on the same.

1. Hot Work (Welding, Grinding, Cutting, Brazing, Hot Rapping) 2. Crane Lifts & Critical Rigging.
□ Flammables /Combustibles (charged gas line, cylinder ,paper, rags, wood, etc.) □ Safety devices (limit switch, boom angle etc.) of the appliances are inspected before use.
is removed or protected if removal is not possible □ Operator qualified and medically fit including eyesight examined by approved medical practitioner.
□ Fire Watch Established □ Lifting appliances are certified by competent authority and labeled properly.
□ Welding & Cutting equipment integrity checked & positioned properly. □ Hoist chain or hoist rope free of kinks or twists and wrapped around the load.
□ Cables / Hoses routed over the ground and do not pose a tripping hazard. □ Lifting Hook has a Safety Hook Latch that will prevent the rope from slipping out.
□ Area hazards reviewed (JSA Done) □ Lifting gears operator been instructed not to leave the load suspended.
□ Electrical connections through ELCB of 30 mA sensitivity □ Electrical power line clearance (as per electricity rule) checked.
□ Electrical equipments are free from damage and earthed properly. □ Signal man identified □ Outriggers supported; Crane leveled.
□ Performer is competent and equipped with appropriate PPEs i.e. including face □ Load chart available in the crane cabin □ Barrier Installed, reflective barrier at night.
shield with adequate shade number /welding goggles / Fire Retardant Apron □ Riggers are competent.
□ No tampering / manipulation attempted in safety device of the equipment. □ Slings are inspected for free from cut marks, pressing, denting, bird caging, twist, kinks or core
□ Only industrial type electrical appliances are in use protrusion prior to use
□ Cables / fuses are of adequate size & capacity fit with the requirement. □ Slings mechanically spliced (Hand spliced slings should be avoided)
□ Hoses are free from damage and connected with Jubilee clamp. □ D / Bow shackles are free from any crack, dent, distortion or weld mark, wear / tear and certified by
□ No cable joint within 1 m from the holder of grinding machine and completely competent authority
insulated within M/C body. □ Special lift as per erection / lift plan (Lift Plan mandatory for all lift >5 tons)
□ Gas cylinders used: Oxygen / Industrial LPG / Dissolved Acetylene □ Job Hazards is explained to all concern thru toolbox talk meeting (JSA Done)
□ Gas cutting torch of reputed make, ISI marked, installed with NRV / 3-way torch □ Proper Guide rope is provided while shifting / lifting.
and / or Flash back arrestors are in use. □ Maintenance record of crane available
□ Regulator pressure gauges in working condition, visible and not damaged. 3. Electrical Work
□ Welding cable and earthing cable are crimped with proper size lugs and other □ Power supply locked and tagged □ Circuit checked for zero voltage.
joints are not allowed. □ Portable cords and electric tools inspected □ Safety back-up man appointed.
Fire Protection □ Physical isolation is ensured If yes, State the method _______________________
□ Combustible gas or liquid containers removed □ Area wet down □ In case of lock applied, ensure the safe custody.
□ Spark / Spatters shields / Ceramic Cloth installed / used. □ If physical isolation is not possible state, the alternative method of precaution/isolation.
□ Other (explain) ________________________________ □ Potential energy discharged through discharge rod.
Equipment Provided □ 3 way power tester is available for testing live system □ Electrical shut down to follow LOTO
Fire extinguishers Type: □ CO2 □ Dry Chemical Powder □ Other ______________ □ Recheck to be sure about correct panel for work.
Size_____________________ Quantity __________________ Equipment Provided
4. Excavations Exceeding 1 m (3 ft.) □ Approved gloves, Suitable electrical shoes □ Insulating mat
□ Contractor has a competent person to inspect & control condition of □ Fuse puller □ Non-conductive hard hat
excavation. □ Disconnect pole or safety rope □ Cool Coat/Electrical Flash Suit
□ Underground utilities identified  Power equipment grounded. □ Earth Leakage Circuit Breaker (ELCB)
□ Electrical or mechanical overhead clearances checked. 5. Scaffolding Erection & Dismantling:
□ Protective/Indicative Barricading (beyond 1 m from edge) done, area warning □ Presence of competent person assigned to ensure safe erection, maintenance, or modification of
placed. scaffolds.
□ Means of egress (ladder or steps) placed. □ Scaffolders inspected for proper access, egress by competent persons. Green Tag visible.
□ Side walls shored or laid back. □ All pipes, clamps, H-frames, couplers, boards checked before assembly.
□ Area adequately lighted □ Standard guardrail (900-1050mm top rail, 500 mm mid-rail, and 90- 150 mm toe board) been used
□ Material or soil removed from excavation edge. whenever possible.
□ Excavator is fit for the job. □ Platforms, walkways on scaffolds are wide of minimum of 600 mm wherever possible
□ Banks man provided to guide the operator. □ Precautions taken to ensure scaffolds are not overloaded.
□ Method of dewatering is established and ensured the stoppage of water return. □ Overhead protection provided where there is exposure.
□ Excavated pit edges free from heavy over-burden, stack of materials. □ No opening / Gap in the platform / walkway.
□ People are prevented from working inside pits if heavy vehicle movement in the □ All component of the scaffold away from any exposed power lines (as per electricity rule)
vicinity due to which soil collapse may take place.
6. Height Work (More Than 1.8 M High) Contractor procedure in place: Y / N
□ Only medically fit personnel engaged in work and list is available. 7. Hydro / Pneumatic Testing: Is work to be performed planned: YES/NO, (If No – STOP)
□ Ladder(s)/ Approach way inspected prior to use □ Access/egress, Hot work, Other on-going work considered in plan
□ Safe access & egress ensured □ Specific hazards in the work area identified (JSA done)
□ Ladder properly supported and leveled □ Area cleared from non-test personnel and barricaded
□ Tied Top □ Tied Bottom □ Discharge of safety relief valves directed away from personnel area
□ Distance between the ladder support and the ladder base is at least ¼ the total □ Compressor is certified by the competent authority
length of the ladder. □ Safety release valves and NRVs of system are in working condition
□ Ladder been provided with skid resistant feet. □ Pressure gauges are calibrated and identified for the job.
□ Scaffolds/platforms inspected for suitability and proper construction (secured □ Formal discussions with personnel performing work or affected by this work held
flooring and guardrails) □ Workmen instruction for not attempt the tightening / loosening of bolts and hammering while the
□ Work area roped off and warning signs in place. line is under pressure
□ Proper Housekeeping is done 8. Confined Space (CS)
□ Floor opening covered / guarded. If not, Personnel briefed about floor opening □ The written confined-space entry program is firmly implemented and being enforced.
& other hazardous / Warning displayed. □ Whether permit issued after verification of LOTO system for all upstream and downstream
□ Tools and other equipment secured in safe manner to prevent accidental fall equipment as applicable with respect to Process Flow Diagram (PFD)
□ Area cleared below prior to start of work / Barricaded. □ Whether CS numbered, warning displayed, PFD available with required isolation for job.
□ People at height are secured. □ Is there a qualified stand-by man deputed?
Equipment Provided □ Does he/she maintain a list of personnel entries with sign and date/time of entry?
□ Roof Top: Crawler Board / Securing arrangement checked □ Gas / Oxygen deficiency/ presence of toxic – flammable vapor test done and found ok.
□ Full body Harness with double lanyard and anchored to independent rigid □ Are only 24V hand lamps used inside the confined space?
object. □ Proper means of exit/ evacuation/ rescue arrangement provided.
□ Lanyard with rope grab shock absorber/fall arrestor □ Proper ventilation and lighting provided
□ Safety net is provided but not less than 5 M from the work area / NA.
9. Suspended man basket / Platform
□ Use strictly controlled method □ Certified by competent authority. 10. ENERGIZED ELECTRICAL WORK(If Physical Isolation /De-Energize not Possible )
□ Lifelines and harnesses approved type with separate anchorage. □ Detailed job description and safe work procedure to be followed in performing the above energized electrical work.
□ Communications established □ Basket properly labeled with load capacity. □ Identification of electrical hazards and determination of flash & shock protection boundaries
□ Lifting appliances are certified by third party competent authority. □ Ensure necessary PPEs and job briefing including hazards before starting the work.
□ Guardrails are provided □ Workmen are competent and medically fit. □ Safety Means employed to restrict the access of Unqualified Personnel from the work area
□ Proper means of access is provided to the work platform. □ Two or more electrically Authorized Personnel present to work on equipment operated at or above 600 V (list names):
□ Lifting appliances operator never leave the site while man bucket is in use. □ Ensure resources for First Aid/CPR assistance available within 4 minutes at work area for all work at 50 V or more.
□ Kept at secured mode while not in use. □ Do you agree the above-described work can be done safely? If no, return permit to Facility Manager / OAP
11.General Work /Housekeeping: 12.Other as Applicable:
□ Ensure work Boundary identified by putting Hard Barricading /Warning Tap/ Verbal
□ Proper access to work area available. □ Working platform/ area is protected from fall hazards
□ Free from Electrical Hazards □ No energize & unguarded equipment in work areas.
□ Proper illumination & ventilation □ JSA & HIRAC available for said activity
Note 1: Working area should have communication board on Job details indicating site In-charge, Safety In-charge, mobile number, space for displaying permit sheet.
Note 2: List of persons engaged in the job may be maintained in separate register.

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