COLD WORK PERMIT Form # HSEQ - CWP Rev 2.docx

Issue Date: _______________ Permit No: ____________
Permit Requested By: __________________ Company Name: ________________ Permit Accepted By: __________________ Company Name: ________________
Validity From: __________ To: __________

1. Job Location: _____________________________________________________________
2. Job Description: __________________________________________________________
________________________________________________________________________________________________________________________________________________
3 Tools & Materials to be used:
❑Explosive Device ❑Sandblaster ❑Jack hammers
❑Hand Tools ❑Drill ❑Jack hammers
❑Powered Excavation Equipment ❑Powered cutting Saw ❑Ladder/Scaffolding
❑Air Heater ❑LPG Gas ❑Others

4- Details of potential hazards:

❑Falling from height ❑ Material Fall down ❑Skin Exposures
❑Electrocuted ❑ Slip and trip ❑Burn out due to fire/acid etc.
❑Exposure to Eye ❑ Inhalation of any Gas ❑Breathing Problem ❑Others

5- Details of precaution need to be taken:

❑Caution Signage to be placed ❑Proper fixture an erection of Scaffolding/Ladder
❑Excavated Area fencing ❑Electrical Isolation
❑Fire water supply isolation ❑Fire water tanker to be provided
❑Fire Extinguishers to be provided ❑Exhaust fan to be provided
❑Informed security Et Help Desk ❑Other

6- Details of protective equipment to be used or worn:

❑Safety Shoes
❑Safety Helmet
❑Face Shield/Goggle/Glasses
❑Gloves (As per work)
❑Safety harness/Belt/Lifeline
❑Uniform ❑Respiratory Equipment/Dust Mask
❑Chemical Suite/Apron
❑Ear protection
❑Fire Blanket/Protection Sheet
❑Rubber Mat/Ground Fault Interrupter
❑Other
7- Signature of Permit Requestor:
Contact No:-

8- Signature of PTW Acceptor:
Contact No:-

9- Signature of Permit Issuer/HSE Representative:



10- Signature of handover of responsibility between shifts, if needed.



11- Declaration by competent person in -charge of work that work is completed.


12- Signature of Maintenance / works representative ensuring that the work is
completed, site has been checked and that equipment and place may be reinstated / left
Safely isolated.



13- Signature of person issuing the permit / HSE representative which confirms that the
Site has been left in safe condition and the permit is cancelled.



14- Signature of the management representative signing off the permit to work.



REMARKS:-

1. COLD WORK PERMIT
Page 1 of 2 Form # HSEQ- CWP (Rev 2 – Mar 23)

Issue Date: _______________ Permit No: ____________
Permit Requested By: __________________ Company Name: ________________
Permit Accepted By: __________________ Company Name: ________________
Validity From: __________ To: __________

1. Job Location: _____________________________________________________________
2. Job Description: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
3 Tools & Materials to be used:

❑Explosive Device ❑Sandblaster ❑Jack hammers
❑Hand Tools ❑Drill ❑Jack hammers
❑Powered Excavation Equipment ❑Powered cutting Saw ❑Ladder/Scaffolding
❑Air Heater ❑LPG Gas ❑Others

4- Details of potential hazards:


❑Falling from height ❑ Material Fall down ❑Skin Exposures
❑Electrocuted ❑ Slip and trip ❑Burn out due to fire/acid etc.
❑Exposure to Eye ❑ Inhalation of any Gas ❑Breathing Problem ❑Others

5- Details of precaution need to be taken:

❑Caution Signage to be placed ❑Proper fixture an erection of Scaffolding/Ladder
❑Excavated Area fencing ❑Electrical Isolation
❑Fire water supply isolation ❑Fire water tanker to be provided
❑Fire Extinguishers to be provided ❑Exhaust fan to be provided
❑Informed security Et Help Desk ❑Other

6- Details of protective equipment to be used or worn:

❑Safety Shoes
❑Safety Helmet
❑Face Shield/Goggle/Glasses
❑Gloves (As per work)
❑Safety harness/Belt/Lifeline
❑Uniform
❑Respiratory Equipment/Dust Mask
❑Chemical Suite/Apron
❑Ear protection
❑Fire Blanket/Protection Sheet
❑Rubber Mat/Ground Fault Interrupter
❑Other
7- Signature of Permit Requestor:
Contact No:-

8- Signature of PTW Acceptor:
Contact No:-


9- Signature of Permit Issuer/HSE Representative:

2. COLD WORK PERMIT
Page 2 of 2 Form # HSEQ- CWP (Rev 2 – Mar 23)




10- Signature of handover of responsibility between shifts, if needed.



11- Declaration by competent person in -charge of work that work is completed.


12- Signature of Maintenance / works representative ensuring that the work is
completed, site has been checked and that equipment and place may be reinstated / left
Safely isolated.



13- Signature of person issuing the permit / HSE representative which confirms that the
Site has been left in safe condition and the permit is cancelled.



14- Signature of the management representative signing off the permit to work.



REMARKS:-