1+2, W+Y+G, F & B, Black, Card Bind, 40 Book, 50 Each. No.

001

Hitachi Energy India Limited

SAFETY WORK PERMIT
Date : Time : Permit No :

Name of Contractor : No. of person

BU / Department : Location of work

Description of Work :

Permit Validity Date : Permit Closed By Name : Permit Closed Date :

Date / Time Time : Name & Sign : Sign : Date / Time Time :
Cold Work Height Work Hot Work Electrical and Mech, Lockout / Tagout Excavation Work
Malnt.
Sign Engr/ Sign Engr/ Sign Engr/ Sign Engr/ Sign Engr/ Sign Engr/
Safety Officer Safety Officer Safety Officer Safety Officer Safety Officer Safety Officer
Check & ensure the Yes Does the work Yes Check and ensure Yes Check and ensure Yes Check and ensure Yes Check & ensure Yes
checklist Is filled In Involve more than that working area that equipment that the mains are protocol clearance
for loading & N o 1.5 m height N o does not contain No properly drained N o put off & LOTO N o prepared and signed No
unloading vehicle any combustible and blinded is applied.
e.g.. Hydra, Crane NA NA Material NA NA NA NA
and Forkllft
Check & ensure all Is proper access Check and ensure Check and ensure Check and ensure Check & ensure that
slings (Wire rope & Yes available to reach Yes Cylinders & torch Yes that plant operators Yes Yes Yes
that main fuse / details and clearance
Belts)/ lifting tools & the working spot
tackles are In good N o safely N o are fitted with N o of concerned area N o Control fuse No of under ground / No
flashback arrester have been Informed removed Over Head (OH)
conditions and NA NA NA about work NA NA utilities is available NA
calibration
certificates available

Check & ensure all

machinery are In Yes Check and ensure Yes Lighter is Yes Check and ensure Yes Check and ensure Yes Check & ensure Yes
that all guard available for electrical that main breaker hard barricatlon for
good N o rails, toe board N o Igniting the torch No equipment are N o racked out in test No excavation more No
condition/guarded are In place at the Isolated position than 3 ft
NA working platform NA NA & tagged out NA NA NA

Check & ensure Check and ensure Check and ensure Check and ensure Check and ensure Check & ensure
MSDS/PPE's Yes that proper and safe Yes fire extinguisher Yes equipment is free Yes that equipment's Yes condition of manual Yes
available for the anchorage points available at from flammable / are properly excavated equipment
Chemical work N o are available to N o working area N o explosive vapours/ N o grounded and No No
Which Involve hook safety harness Toxic fumes/Gases earthing is in place
painting, epoxy, Pest NA NA NA NA NA NA
Control etc. others

Check & ensure Check and ensure Check and ensure Check for other Check and ensure Check & ensure
condition of Yes that safety nets are Yes cylinders kept in Yes agency working in Yes that cautionary Yes proper and Yes
portable electrical & in place where upright & chained the same area and warning adequate shoring
Pneumatic / hand N o required and N o in trolley No N o boards are N o of excavated pit Is No
tools for carpentry / advised. displayed at area carried out
other works are in NA NA NA NA of work. NA NA
good condition

Check & Ensure Check and ensure Check and ensure Check and ensure Check and ensure Check & ensure
proper barricaiton Yes that area below the Yes that welding Yes equipment Is Yes that equipment is Yes condition of Yes
and good house- workplace barri- machine and cables Isolated from dead at working mechanical
keeping is N o caded and work in N o are in good N o automatic and N o side. No excavated No
maintained at the the same segment is condition and Instrument valves. equipment
work place. NA restricted NA properly insulated NA NA NA NA

Check & Ensure all Check and ensure Check and ensure Check and ensure Name of technician Check & ensure that
civil activities are Yes that workmen Yes that Electrical Yes proper cautionary Yes carrying out LOTO : arrangement Yes
complied with
N o provided with bag/ N o Connection are and warning
N o boards displayed. No
available to escape
No
proper working Box to carry loose provided with in case emergency
platform / PPE's proper capacity for excavation more
NA materials and tools NA RCCB/MCB NA NA Signature of technician than 10 ft NA
switch's carrying out LOTO :

Any other Job pIs. Yes Check and ensure Yes Check and ensure Yes Check and Ensure Yes Name of engineer Cheek & ensure Yes
specify that proper earthing cable is in that illumination certifying the LOTO : proper ladder &
N o portable ladder N o proper condition N o level and House No ramp provided for No
NA provided as per the NA with Insulated NA keeplng of the area NA safe access NA
Job requirement Crocodile pin is well maintained.

Signature of engineer
Check and ensure Check and ensure Any other certifying the LOTO : Check & ensure
Yes horizontal /vertical Yes that working Yes instructions; Yes excavated/other Yes
N o Life line is Installed N o persons Imparted / N o pIs.Specify No materials to be kept No
as required and trained in fire mln. 5 ft. away form
NA advised. NA safety training NA NA the excavated pit NA

PPEs Required :

Safety Helmet Hand Gloves Cotton /Leather/ Full Body Face / Nose Additional requirnemnt
PVC/Cut resistant Safety Harness Mask Pls. specify
Safety Shoes/ Safety Goggles welding Leather Apron/ Special requirnment
Safety Gum Boot Ear Plug / Ear Muff
Goggles / Sheild PVC Suit Pls. Specify
Remarks :

Name & Sign of Name & Sign of Name & Sign of

In-Charge Contractor Safety In-Charge

Work permit distribution Permit Extension

Contractor Date and time to which extension is
1st Copy (White)
required

Distribution : Name & Sign of Initiator Name & Sign of PG

2nd Copy (Yellow) Initiator
Manager
 GENERAL SAFETY RULES
SAFETY IS EVERYONE'S RESPONSIBILITY"
1. Always display your identity card with you and show it upon request by authority.
2. Walk on the marked walk-ways only.
3. Obey the speed limit & Traffic sense in the premises.
4. Keep the Safe distance from moving vehicles.
5. Safety shoes is compulsory &use other Personal Protective Equipment (PPE's) as directed in work permit
6. Abusive or inappropriate behavior in the work place such as horse play, practical jokes, etc., physical or
verbal strictly prohibited.
7. Consuming or being in possession of alcohol or illegal drugs in the workplace is strictly prohibited.
8. Smoking is allowed only at designated smoking area.
9. Do not ride on trailers, Hydra, forklift except authorized person.
10. Report all unsafe act/ unsafe condition to concerned supervisor/safety officer immediately.
11. Employees including contract people are responsible for reporting to supervisor, whenever they become
ill or injured at work. All injuries, no matter how minor, must be reported immediately.
12. Every employee include contract people shall keep his/her work area neat, clean, orderly and free of
hazards.
13. Failure to adhere safety laws OR Safety rules will be cause for disciplinary action and penalty provision.
14. Penalty provision: 1st Minor Noncompliance - Warning letter; 2nd Minor Noncompliance - Rs. 5000/-; 3rd
Minor Noncompliance- Rs. 10,000/-. Major Noncompliance will either attract penalty of Rs. 10000/- or
termination of work.
15. All employees must be aware of the emergency procedures such as evacuation routes and assembly points,
emergency phone numbers (given below), locations of fire extinguishers, etc.
16. IDENTIFIED SAFE ASSEMBLY POINT :

SR NO. ASSEMBLY POINT EMERGENCY CONTACT NUMBERS :

1 ADMIN BLOCK DEPARTMENT PHONE NO.
2 BOARD M2 Main Gate 117 / 118
3 PAPER PRODUCTION SECURITY M2 119
HOTWORK MAINTENANCE HEALTH CENTRE 123
HOT E&U 170
WORK YES NO SIGN
SAFETY 210 / 218
30 Mts
60 Mts
2 Hours

Contractor Declaration:
I have understood the Environment, Health and
Safety rules and regulation of the organization
and is abide to follow the same.

Name of Contractor :
Agency

Name of contractor :
responsible person

Signature with time

and date