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INTEGRATED CLEANROOM TECHNOLOGIES PVT LTD.
ICTPL/EHS/F:034
PERMIT TO WORK AT HEIGHT
(Above 6 Feet) 1.8 M / ON OR NEAR FRAGILE

ROOF INSIDE ICTPL Premises
Format No.: ICTPL/Admin/EHS/PTW002 Permit No. 20……. / ……. (Year/No)
Description of work_______________________________________________________________________Date__________________
Exact Location of work:_________________________________________________________________________________________
To Mr.______________________________of M/s______________________________________ You are hereby permitted to work as

detailed above subject to compliance with the conditions described below. The permit is valid up to ………………………. (Max. 9hrs.)
Sl No. Description
Has the contractor’s scope of work reviewed and potential hazards assessed and communicated to contractor prior
1 Yes
to start of work and listed below……………………………………………………………………
Has the chemical present in the work area reviewed and communicated to the contractor and listed below:
2 If yes, the chemicals present are……………………………………………………………………………………. Yes/NA
Has the chemical used by the contractor approved by EHS and carry hazard label
3 (The contractor should give one copy of the material safety data sheet to ICTPL) Yes/NA
Has the contractor been requested to provide safety and chemical hazard information like material safety data
4 Yes/NA
sheet, container labeling, safety condition of tools & tackles, knowledge of handling chemicals?
Has the site specific safety information to the contractor employees prior to the start of work and formal safety
5 Yes/NA
orientation session (covering subjects such as emergency evacuation, LOTO procedures and PPE requirements)
6 Are the affected ICTPL personnel informed about the hazards that may arise due to contractor activities? Yes/NA
HAVE THE FOLLOWING PRECAUTIONS IN PARTICULAR BEEN TAKEN

Sl No. CHECK POINTS Sl No. CHECK POINTS
Is the surrounding area checked and the Yes/NA
1 employees have been cautioned and shifted 7 Safety net bounded if required? Yes/NA
to safer place?
Is the surrounding area barricaded and Yes/NA Ensure overhead electrical lines or any sharp
2 8 Yes NA
caution board displayed? objects
Are the required PPE’s (Hand gloves, Apron, Yes/NA
Helmet, Safety glasses, Shoes, Safety belt,
3 9 Is using bag for tools carry at height Yes/NA
Safety harness, Respirator etc.) have been
arranged and will be used?
Is the proper scaffold / ladder provided and Yes/NA Is the standby person deputed to watch and Yes/NA
4 10
tied at top? warn person coming near the work?
Is the working platform provided and Yes/NA Are the employees working at height trained Yes/NA
5 11
supported with structure and training records given to EHS dept.?
Is the safety harness used and lifeline Yes/NA Are the electrical equipments having earthing, Yes/NA
6 12
anchored above the working level? 3 pin plug top and cable in good condition?
NOTE: 1. Please fill all the columns.
The permit to be returned to issuing authority after expiry of valid time every day and if work to be continued obtain the permit same day
/ next day
Acceptance: I have read & understood this permit & agreed to work in accordance with its requirement
Signature of Contractor Representative Signature of Area In-charge Signature of Issuing Authority (EHS Dept.)
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Name of the contractor Employees trained on Site specific information & formal safety orientation
Name Signature Name Signature
Additional precautions to be taken, if any:

1) __________________________________________________________________________________________________________
2) __________________________________________________________________________________________________________
3) __________________________________________________________________________________________________________
Please enter following details each time the permit is returned and renewed. Do not leave any blank column.
Date Time Sign Date Time from To time Approval Sign
Permit returned Renewed
Job completed and permit returned. Date ______time_____ Signature of the contractor representative______________________
Procedure for obtaining the permit:

1. This permit is required for all jobs i.e., work at height (above 6 ft) , work above false ceiling inside
2. The permit should be filled in duplicate by the area in-charge, while inspecting and examining the site using checklist. The permit to
be issued in the name of contractor or his representative undertaking the job. The area in-charge while reviewing each check point
should assess, predict or foresee the hazard, encounter during course of activity and take or suggest precautionary measures to
eliminate control or contain the hazard. The precautions to be taken by him /herself or by the contractor must be clearly written and
documented.
3. The area in-charge must obtain the permission of EHS to verify that the job hazard identification has been done and appropriate
precautions have been taken.
4. The contractor must take all necessary precautions prior to start of work and comply the permit conditions till the completion of the
task.
5. The orignal copy will be given to contractor or his representative undertaking the work and will be retained by him during progress of
work. Issuing authority will retain the duplicate copy
6. The permit will be issued maximum for 9 hours. The permit to be returned to issuing authority at the end of validity time and can be
renewed again upon verifying the site conditions on the same day or subsequent day following the step - 2 procedure as above.
7. The permit can be withdrawn by area in-charge / EHS at any time, if it is considered that continuation of the job can lead to risk due
to changes in site conditions or in the event of any violations or accident / incident or near miss reported during the course of work.
8. The permit will be revalidated only upon investigation of such accident / incident or near miss by the EHS / Area In-charge and
implementation of corrective actions.
9. The permit to be returned to EHS / Area in-charge after cleaning / clearing of area and restoring the normalcy on completion of job.
Site-specific safety information:

1. If you are on a temporary badge, do not leave the escort while you are inside the premises
2. Understand the evacuation procedure from your escort, as it may be required during any emergency
3. In case of an emergency (Fire / Toxic gas release / Medical emergency / chemical spill) at work area, dial emergency numbers
mentioned above and report the event to the Security/ERT while giving you name, location and nature of emergency. Give brief
description of the emergency.
4. In case you hear a fire alarm or siren, evacuate the work area and assemble at the Safe Assembly point. Help the Security/ ERT
member(s) in head count
5. Do not re-enter the work area until the Security/ ERT member makes “All-clear” announcement / communication
6. Report every accident or near miss to the Area in-charge and EHS team and help him / her in investigating
7. Do not smoke/carry any form of Tobacco inside the premises. This is a “Tobacco free campus”
8. Please obey all safety signage
9. Wash hands and face thoroughly before taking food or beverages
10. Follow ICTPL work permit procedure. Any Hazard noticed should be communicated to Area in-charge and EHS
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INTEGRATED CLEANROOM TECHNOLOGIES PVT LTD.

(Above 6 Feet) 1.8 M / ON OR NEAR FRAGILE

To Mr.of M/s________ You are hereby permitted to work as

HAVE THE FOLLOWING PRECAUTIONS IN PARTICULAR BEEN TAKEN

NOTE: 1. Please fill all the columns.

Additional precautions to be taken, if any:

Procedure for obtaining the permit:

Site-specific safety information:

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