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COLD WORK PERMIT FORM
(For Company Use Only)
Permit Details
Company Name
Permit No
Department / Section
Date Issued
Valid From
Valid To (Max 8 hours)
1. Work Details
Exact Location of Work
Nature of Work
Mechanical Work
Electrical Work
Instrument Work
Piping Work
Other:
Job Description
Equipment / Tools Used
2. Personnel
Permit Requester (Employee/Contractor)
Work Operator(s)
Supervisor Responsible
Fire Watch Assigned (Name & Contact)
3. Mandatory Safety Checks (To be Verified Before Work Starts)
Work area inspected and cleared
Adequate lighting available
LOTO (Lockout/Tagout) applied as required
Fall protection provided if working at height
Electrical isolation confirmed
Tools and equipment inspected
Adequate ventilation ensured
Proper lifting equipment and procedure for heavy items
PPE provided and used (helmet, gloves, goggles, respirator if required)
Work area barricaded and safety signages posted
4. Gas Test Results (If Required)
Oxygen Level (%)
LEL (Explosive Gas) (%)
Toxic Gas (Type/Reading) ppm
Test Done By
Date/Time
5. Authorization
Permit Issuer Name
Signature
Date
Area In-Charge Name
Signature
Date
Work Operator Name
Signature
Date
6. Closure of Permit
Completion Time
Date
Area inspected after completion
Safe
Unsafe
Fire Watch duration completed (min 30 min)
Yes
No
Permit Closed By Name
Signature
Date
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