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Permit / Revision: 02
Date of issue: 18-01-2018
Page: 1 / 2
SECTION 1: (Trade-Contractor carrying out the work to complete)
Contract No. & Site:
Contractor:
Description of work:
Team completing work: / Name: / Position:
Competent Person supervising the works
Other members of the team
Location:
SECTION 2: Attachments: (Trade-Contractor carrying out the work to complete)
Method Statement: /
Y / N
/ Approved Method Statements No(s):Checklist /
Y
/Permit will not be approved if check list not attached
SECTION 3: AUTHORISATION (Site Manager’sauthorised person)Any special Precautions required
The persons designated above (and only those persons) are hereby granted permission to enter and work in the confined space in accordance with the approved Method Statement & Risk assessment.
Permit to Commence: / Date: / Time:
Permit to Expire: / Date: / Time:
This Permit CANNOT cover more than one shift and can only be issued for the maximum of a 12 hour period
Date: / Position:
Name: / Signature:
SECTION 4: ACCEPTANCE OF PERMIT (Trade Contractor’s Competent Person to complete)
I hereby confirm that all persons under the control of our Company will abide by the conditions of this permit.
Date: / Position:
Name: / Signature:
SECTION 5: Completion of work (Trade Contractor’s competent person to complete)
The work for which this permit was issued is complete (or stopped) and all persons, materials and equipment under my supervision have been withdrawn.
Date: / Time:
Name: / Signature:
SECTION 6: WORKS COMPLETE (Site Manager’sauthorised person)
I certify that the work specified above has been satisfactorily completed.
Date: / Time:
Name: / Signature:
Comments:
THE PERMIT IS NOW CANCELLED - A NEW PERMIT WILL BE REQUIRED IF WORK IS TO CONTINUE
This checklist must be completed by the Trade Contractors Competent Nominated Person and reviewed by theSite ManagerAppointed Person before a Confined Space Entry Permit can be issued. A copy of the checklist must also be attached to the permit and its findings briefed to all operatives entering the confined space.
Yes / N/A / Comments1 / Has a risk assessment and method statement been approved?
2 / Are all those entering the confined space trained and competent?
3 / Is the correct PPE identified on the risk assessment, readily available and fit for use?
4 / Is there adequate access and egress?
5 / Is an emergency and rescue plan in place and approved?
6 / Is adequate emergency and rescue equipment in place?
7 / Has the rescue team been trained in its use?
8 / Has a system of communication been established and are emergency contact numbers available?
9 / Is there a requirement for forced ventilation to be in place? If so, what type?
10 / Has the atmosphere been monitored prior to entry and the results recorded?
11 / Has the monitoring equipment been calibrated?
12 / Is the monitoring equipment correct, i.e. is it capable of detecting gases, lack of oxygen or flammable atmospheres etc.?
13 / Have all those entering the space been briefed on the monitoring equipment and what to do in the event of an emergency?
14 / Have all possible harmful substances been removed from the space?
15 / Have all services to the space been isolated or disconnected? If yes, who is responsible for continued isolation?
16 / Is breathing apparatus required? If so, what type and is it HSE approved?
17 / If BA is required, are all persons competent in its use?
18 / Are all the necessary signs and barriers available?
19 / Is intrinsically safe task lighting available?
20 / Are any other Permits required i.e. Hot Works?
Name: / Position:
Signed: / Date:
(NB Only questions 9, 14, 15, 16, 17 and 20 can be answered N/A).