Preview Electrical Work Sample Receipt

Example

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Permit Serial Number

PERMIT TO WORK (ELECTRICAL)

ORIGINAL

Complete precisely and legibly in BLOCK CAPITALS using BLACK or BLUE ink

PART 1: ISSUE - To be completed by the Authorised Person (Electrical)

To:

……………………………………………………….

Employed by:

…………………………………………………………

I hereby declare that it is safe to work on the following apparatus, which has been made dead, isolated, and where necessary, earthed

……………………………………………………………………………………………………………………………………………

………………………………………………………………………………..……

Safety Programme No.:

…………………

TREAT ALL OTHER APPARATUS AS DANGEROUS

Points of Isolation with Caution

Notices posted:

……………………………………………………………………………………………………………

Safety Lock No.: ……………………….

The apparatus is efficiently

connected to Earth at the

following point(s):

……………………………………………………………………………………………………………

The following supplies to the

apparatus are not isolated:

……………………………………………………………………………………………………………

Special Precautions:

……………………………………………………………………………………………………………

The following work is to be

carried out on the apparatus:

……………………………………………………………………………………………………………

State of automatic fire

protection equipment:

Not Applicable:

Detection Only - Isolated:

Detection Only - Operational:

Suppression System - Safe:

Suppression System - Operational ― Make Safe Before Entering:

Fire Alarm Isolation and/or Hot Works Permits may also be required

I have physically identified the equipment and explained the extent of the work to the prospective Person in Charge.

I have shown the prospective Person in Charge the Safety Arrangements at the Points of Isolation and the places of work, and I have explained all

the relevant safety procedures and precautions.

Signed:

…………………………………

(Authorised Person)

Print Name:

………………………………..

Contact Tel. No.

…………………………………

Date:

……../………/……..

Time:

…....…..:…….….

PART 2: RECEIPT - To be completed by the prospective Person in Charge

I have read this Permit to Work and fully understand on which equipment I am permitted to work and the work to be carried out.

No attempt will be made by me or by any person under my charge to carry out any other work.

3)*

a) The Authorised Person has demonstrated to my satisfaction that the equipment is dead and safe to work on.

b) (For LV only) It was not practicable for the Authorised Person to prove the equiment dead prior to the issue of this permit. I will confirm

the equipment dead to my satisfaction as soon as conductors have been made accessible to a suitable test indicator.†

c) It was not practicable for the Authorised Person to prove equipment dead prior to the issue of this permit. I understand the Authorised

Person will confirm the equipment dead to my satisfaction as soon as conductors have been made accessible to a suitable test indicator.†

* Tick box as appropriate; † Test indicators should conform to HSE safety guide HSG85 (2007) paragraphs 53-56

Signed:

…………………………………

(Person in Charge)

Print Name:

………………………………..

Contact Tel. No.

…………………………………

Date:

……../………/……..

Time:

…....…..:…….….

ALL ACCESS KEYS MUST BE RETURNED AT THE END OF EACH WORKING DAY

PART 3: CLEARANCE - To be completed by the Person in Charge

I hereby declare that all persons under my charge have been withdrawn and informed individually that it is no longer safe to work on the apparatus

specified and that all tools and equipment have been removed..

Signed:

…………………………………

(Person in Charge)

Date:

……../………/……..

Print Name:

…………………………………

Time:

…....…..:…….….

Print Name:

…………………………………

Time:

…....…..:…….….

THIS PERMIT IS NOT VALID UNTIL PARTS 1 AND 2 ARE SIGNED

PART 4: CANCELLATION - To be completed by the Authorised Person (Electrical)

1)*

I confirm that all work described in Part 1 of this Permit has ceased

The Original sheet of Part 1 and 2 of this Permit has been returned to me and destroyed.

This Permit is cancelled.

* Tick box as appropriate

Signed:

…………………………………

(Authorised Person)

Date:

……../………/……..

This Sheet to be issued

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