Cold Work Permit

________________________________________________________________________________________

Date_____/_____/_______ Permit Number______________________

(Tick appropriate boxes/Be specific while filling the report, permit issued is only for a specific duration and must be revalidated &
reissued suitably. Permit stands cancelled during any emergency at site.)

Details.

Name of the responsible person Company

_____________________________________________ _______________________________________________.

Location of work Area

_____________________________ ____________________ _______________________________________________.
Duration of works
From _____________To_____________ Time_____________ To_______________
Number of workers / labors
________________________________________________________________
________________________________________________________________

Type of Construction_______________ Environmental_________________ Other------ maintenance

Operation: ______________________ ___________________________ ___________________________
Indicate Type of Work: Cold Work □ Tank Cleaning Electrical □ Maintenance other (specify)

□ □ □
Purpose / Description of Work

Description of Hazard: Special Instructions:

Yes No N/A Commen

ts
1. Has the work area been examined and reasonable precaution taken to ensure that no
potential hazards exist and that no other work in the area could create a hazard while the job
is in progress
2. Have wind, atmospheric, and work area conditions (e.g. cold, hot, poor lighting) been
considered throughout the job so that work can be done safely?
3. Have all underground and overhead power lines, pipelines, or other hazards been located
and staked properly?
Have proper signs been put in place?
4. Are barricades and warning signs in place?
5. Are motor vehicles, EQUIPMENT permitted in the work area,
5(a) Do engines require positive air shut offs? (required for diesel)
6. Do safe work procedures exist for the job? and
Have they been discussed with the contractor? Method Statement/Risk Assessment of the
activity in place.
7. Is special safety equipment or personal protective equipment required?
□ Goggles / Face Shield / Safety Glasses □Hard Hat / Gloves □ Hearing Protection
□ COVERALL Clothing □ Footwear
□ Safety Harness / Lifeline
 Cold Work Permit

________________________________________________________________________________________
Yes No N/A Commen
ts
8. Attach list of all MSDS sheets if required?
9. Do workers attended the safety induction?
10. Have Working Alone considerations been taken into account?
Identify communication protocol.
11. Has a SAFE START Meeting been held? Attach minutes to this copy.
12. How many workers does the permit cover? (List names on SAFE START).
14. Are lanyards and safety harness available for heights over 1.8 m?
15. Is scaffolding required? (over 1.8 m and harness cannot be used)
17. Is dip tray is required?
18. Maintenance works for plant/Equipment needs LOTO system? LOTO permit to apply
attach along with this Permit
19.Supervision of the maintenance works required?
20. Competency of the maintenance works required?
AGREEMENT: I understand and agree that no work is permitted other than that specified on this permit. I have checked both the
permit and the job and I understand the nature and extent of the work and the precautions to be followed in completing the work. I
also agree that any other employees or sub-contractors who will, or may work on this job shall have a complete understanding of
the conditions of this permit and will also work under the conditions of this permit. This permit must be returned at the end of the job
or the end of the day.
Permit Receiver: Signature of responsible person: ____________________________Name: ___________________________

Company Name________________________________________________________________________________________

Time:_____________________________ Date: _____ /______/___________

Permission granted for this work

Project Engineer

Name Signature:

APPROVALS: Name of Issuer (print): ___________________________ Signature: __________________ Title: ________________

Job Complete: _____ Yes _____ No.

If no, explain: __________________________________________________________________________

Time of Completion: (Date :) _______________________ Time: __________________