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HSE 11 Confined Space Permit

This document is a confined space permit that outlines safety procedures and authorizations for work to be done in a confined space. It includes sections for work requests, checklists, gas test results, protective equipment, additional precautions, acceptance of safety procedures, and close out upon completion or cancellation of work.

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Ba N Nhim
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136 views1 page

HSE 11 Confined Space Permit

This document is a confined space permit that outlines safety procedures and authorizations for work to be done in a confined space. It includes sections for work requests, checklists, gas test results, protective equipment, additional precautions, acceptance of safety procedures, and close out upon completion or cancellation of work.

Uploaded by

Ba N Nhim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CONFINED SPACE PERMIT

This permit must be displayed prominently at the work area


This permit is valid from (a.m/p.m) to (a.m/p.m) on day of issued

SECTION A - WORK REQUEST


Contractor:
Location: Date: Time:
Specific Work Area:
Equipment to be worked on:
Description of work:

JSA No: N/A

SECTION B - CHECKLIST YES N/A SECTION C: AUTHORIZATION


1 Check area and equipment to be worked on 16 Permissionics hereby given to the bearer of this permit to
carry out the above mentioned work under the provisions
2 Surronding condition is safe to work
stipulated iun this permit and in accordance with the Work
3 Source of ignition nearby Permit System
4 Equipment properly blanked and isolated
5 Sufficient fire fighting equipment available
6 Check area / vessel to be entered
7 Gas tset required before permit is issued
8 All required manholes of vessel opened
9 Portable lighting used of low voltage Signature by: Contractor Site Managers/Executives
10 Ventillation equipment installed SECTION D: AUTHORIZATION
11 Entrants / standby supervisor identified 17 Permissionics hereby given to the bearer of this permit to
carry out the above mentioned work under the provisions
12 Special waring / barriers provied
stipulated iun this permit and in accordance with the Work
Combustibles Toxic Oxygen Permit System
13 Gas Test Result
14 Protective equipment to be used:
Rubber boots Hard Hat Safety harness
Gloves Face Shields Hearing protection
Safety Shoes Safety Glasses
Signature of Haskoning' representative
15 Additional Precautions to be taken: SECTION E: ACCEPTANCE
18 I understand the scrop of work to be done and safety
precaution to be taken. I agree and accept all the
provisions procedures and shall cease work should
condition affecting safety aspect of the work changes

Signature by: Perfoming Authority: Contractor supervisor


SECTION F: CLOSE OUT
19 Completion/Cancellation
I certified that the above mentioned work has been completed
has not commenced
(Tick as appropriate) has commenced but is not complete

Signed: Name: Time: Date:


(Performing Authority)
I declare that this permit is now withdrawn and cancelled.

Signed: Name: Time: Date:


(Approving Authority)

1st copy: Post At Job Site 2nd copy: keep to file 3rd copy: to HSE

Version 00 HSE-11-Confined space


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