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To be filled before starting the work and first copy to be available at work site with performer (internal / external), the second copy to be submitted to security post, & third copy shall be retained in the book itself.

Note:
1. Under no circumstances permitted work should be carried out after the close time of the work permit.
2. Permit should be returned to the initiator by performer & thereafter submitted to EHS Coordinator.
3. Safe work permit request should be raised daily before start of work & permit register shall be available with EHS Coordinator.
Doc. No: {DocNo}
Rev No: {RevNo}
Rev Date: {RevDate}

{CategoryName} Permit

Permit No. Date Time
(Max 8 hrs or end of the shift)		 Work Performing Department Location of Work
{WorkPermitUID} {CreatedOn} From {StartDateTime}
To {EndDateTime} 		{DepartmentName} {Location}

Work Description: {Description}
{ElectricalSpecificRows} {DynamicSections}
{PermitAuthorizers}
4. Work Permit Authorization
Cross Referred Permits – To be filled by Initiator
(Other type of Work Permits for Same Work) 		Permit Type: {CategoryName}
Permit No.: {WorkPermitUID}

5. Permit Acceptance

I have been explained the contents of this permit. I shall be responsible to supervise the job as mention in permit. I will assure you to follow all the safety precautions including uses of required PPE's as per plant guideline.

Name & Sign of the Job Performer / Contractor's Supervisor : Name & Sign of the Permit Initiator:

6. Work Crew Tool Box Talk (Attached Separate sheet if require)
S. No. Name of Person Engaged in Activity Job Profile Signature Name of Person Engaged in Activity Job Profile Signature
Contractual employees covered by ESI or any other policy - Yes / NO (HR Head & Plant Head approval is required if mentioned as NO) – Both Signatures: __________ / ___________

{PermitExtensionSection}
{WorkPermitClosureSection}
{WorkPermitHistory}
Work Permit History
Date Modified By Comments Attachments