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Site id IN-1370362/I-RJ-CHHN-AG1-9060 Site name Barmer

PTW NO TVH/001 District BARMER


Circle Rajasthan Submitted by
Submitted date 13/01/2019 Activity type
Approved By Project manager Approved Date
Authorized By Audited By Safety manager Authorized Date
TSP Lead
Personal Protective Equipment
Safety harness yes Eye protection yes
Hand protection yes Foot protection yes
Protective clothing no Safety helmet yes
Approval
Status Approved Remarks All ppes ok
1 @risk Declaration
1 Supervisor Name Mobile Number Sitaram singh -9610402233
Power Lines
Ensure Minimum Safe Clearance Between Any Material/Conductor/Person
11KV minimum safe Safe 33KV minimum safe clearance is Safe
clearance is 1.2mtr 1.4mtr

132KV minimum safe Safe 220KV minimum safe clearance is safe


clearance is 3.3mtr 4.1mtr
400KV minimum safe Safe
clearance is 5.5mtr

Crane/Hydra
Inspection prior to use yes Valid 3rd party certificate yes
Safe working load yes All limit switches working yes
mentioned
Crane operator / fork lift yes Safe access yes
competency ok

Safety latch in place yes Outriggers used yes


Soil/ floor condition good yes manual / hydra hydra
enough to bare the crane &
material load

Chain Pulley Block


Inspection prior to use yes Check for crack and damage yes
Safe working load yes Valid 3rd party certificate yes
mentioned
Safe latch in place yes material weight 400 kg

Site Condition
Access for crane yes Housekeeping acceptable yes
movement
Tools
Approved/Appropriate yes Tools in good condition ok
tools

Tools inspected by yes Team compitant


competent person in last
six month

Personal Protective Equipment


Safety harness yes Eye protection yes
Hand protection yes Foot protection yes
Protective clothing yes Safety helmet yes
Tool box tal conducted yes Lifting lanyad ok/not ok ok

Fitness of Personnel
Personnel suffering from safe Personnel under influence of no
illness including alcohol/heavy medication
cough/cold

Precautions
Warning notice & safety yes Unpacked material has been yes
signed provided disposed properly from sites
Special precautions are all ppes wareing after work start

Self Declaration
Declaration
I .sitaram singh..agree to work within the condition indicated on this permit & accept the responsibility as the person directly in
charge of the work. I declare a l the work at height or material or electrical wil be carried out in accordance with the requirements
of the work permit system.
Name of supervisor - signature

Authorization / Audit
Status Authorized Remarks approved
sr660012002

sr66012775

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