Royal Docks Waterways Electrical Safety Permit to Work
Royal Docks Waterways Electrical Safety Permit to Work
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Company Name
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Project Title
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Location
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Contract number
Permit number
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Site
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Issued to
Issued to
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First
Last
Job
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Treat all other electrical apparatus in the area as dangerous.
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The apparatus is effectively connected to earth at the following points
The points of isolation are as follows
Arrangements for the display or retention of the keys to locking-off devices are as follows
Caution notices have been posted at the following points
Safety locks have been fitted at the following points
Description of the work to be carried out
Diagram of works
Reference drawings
Sign off from authorised person: I hereby declare that the high-voltage apparatus in the area specified is dead, has been isolated from all live conductors and is connected to earth.
Sign off from authorised person: I hereby declare that the high-voltage apparatus in the area specified is dead, has been isolated from all live conductors and is connected to earth.
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First
Last
Position
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Draw your signature into the box below.
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Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
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DD
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MM
YYYY
I hereby declare that I accept responsibility for carrying out work on the apparatus detailed on this permit to work and that no attempt will be made by me, nor by any person under my control, to carry out work on any other apparatus in the area.
I hereby declare that I accept responsibility for carrying out work on the apparatus detailed on this permit to work and that no attempt will be made by me, nor by any person under my control, to carry out work on any other apparatus in the area.
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First
Last
Postion
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Draw your signature into the box below.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
*
/
DD
/
MM
YYYY
Note: after signature for work to proceed, this receipt must be signed by, and the permit to work retained by, the person in charge of the work, at the place where the work is being carried out, until work is suspended or completed and the clearance section has been signed.
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