COLD WORK PERMIT

CWP No.:
Permit Requester details: Special protection, PPE required: YES N/A
Name Signature Badge No. Date Time Rubber gloves Goggles Dust mask Disposable suit

SECTION-5
Rubber boots Face shield Half-mask respirator Chemcial suit
SECTION-1

Details of work activity: Full body harness Doulbe ear protection Other __________________________________________

Equipment details Work execution details

SECTION-7 SECTION-6
Dept./Plant Unit Name / No. Equipment Name/Tag No. Service department / Contractor Work order No. Affected area supervisor's confirmation: YES N/A
Plant ___________ Name _____________________ Signature _______________ Date _________ Time _______

Description of work: Special precautions, if any_______________________________________________________________________

________________________________________________________________________________
Authorisation (After JOINT SITE VISIT)
Tools to be used: Valid from __________ hrs. to __________ hrs. Issue date ________________ Time __________ hrs.
SECTION-2

SECTION-8
Hand tools Transmitters Calibrtor Portable ultrasonic meter Permit Issuer Permit Receiver
Multimeter Vibration monitoring Temperature measuring IR gun I have checked & certify that the conditions & precautions requried are I hereby accept the stated conditions & precautions for the work to be
as stated & work can be carried out safely done safely
Portable Ladder (height < 1.8 m) Other ____________________________

Name ________________________________________ Name _______________________________________

Hazards check list: Certificate No. ________________________________ Certificate No. _______________________________
Flammable gas O2 Deficient atmosphere Trapped gas/ liquid Slippery Signature ____________________________________ Signature____________________________________
SECTION-3

Toxic gas/fumes Dust/fibres/catalyst Corrosive chemicals Electrical Renewal of Permit

Volatile liquid Heat stress Frost-bite Radiation Permit Receiver Permit Issuer

SECTION-9
High pressure Steam/condensate Carcinogenic Finger trap Name Cert. No. Signature Duration Name Cert. No. Signature Date Time

High temperature Working at height Rotating equipment Other __________

Equipment preparation check list (if answer is NO, give justification in special precautions):
Description YES NO N/A
1. Equipment/line isolated, drained/depressurized, purged & tagged? Permit close-out
2. Work area clean & free from combustible materials? Permit Receiver:
SECTION-4

3. Manholes, catch pits/basins, sewer connections are covered? Work is completed YES NO
SECTION-10

4. Process vents & manhole vents direct away from wrok site? If, work is not completed, state reason ____________________________________________________________
5. Radiation source is removed / locked? Housekeeping completed YES NO
6. Toxic / flammable materials within 15 m work area removed? Name ___________________________________Signature ____________________ Date _________ Time _______
7. Work area barricated? Acceptance by Permit Issuer:
8. Will this work affect operations or other maintenance jobs within 15 m radius? Confirm work completion status & housekeeping onsite
9. Will this work affect DCS operations? Name ___________________________________Signature ____________________ Date _________ Time _______

NOTE: 1) Tick ( √ ) for applicable boxes in the permit 2) Perform TAKE TWO before starting the job 3) Hardcopy to be displayed at worksite until close-out and then exchange the copy with permit issuer