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NOTE: Additional Respiratory PPE may require use of a Confined Space Permit. <br />Job Site Preparation (Check appropriate boxes) <br />Equipment Lines/Valves Vessels/Tanks Energy Sources <br /> Drained & Depressured Neutralized Power Panels <br /> Blinded Labeled Pneumatic/Air <br /> Blocked/Closed Not Applicable Hydraulic <br /> Liquid(s) Neutralized Adequate Ventilation Transformer/Main Breaker <br /> Disconnected Drained & Depressured Flowing or Pressurized Liquid <br /> Labeled Chemical/Gas <br /> DAILY WORK PERMIT <br />Project #___________________ Date:______________________ <br /> Thermal <br /> Not Applicable <br /> Water <br />Permit User(s): <br />By signing this permit you are indicating that yourself and all workers covered by the permit have properly logged into the work area, and the contents of each <br />required permit will be communicated to them. <br />Permit Writer: <br />By signing this permit you are indicating that the scope-of-work and site has been evaluated and you will comply with permit requirements at a minimum. <br />Additional testing, beyond the plant or facility procedures, including blinding, lock out / tag out, energy isolation associated with permits must be reviewed and <br />discussed with client, ICS operations management, project management and contractors to ensure safety. <br />Superintendent: __________________________________________Phone: _______________________________Emergency # ________________ <br />Exact Location Onsite: <br />___________________________________________________________________________________________________________ <br />Description of Work and Purpose: __________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________________________ <br />JOB INFORMATION <br />Client: ___________________________________________________________ Site Name:_________________________________________________ <br />Address: ________________________________________________City:_________________________________State: ______________________ <br />Time Issued: ____________________ AM or PM?*Hot Work *Confined Space Entry <br />Time Expires: ___________________ AM or PM?*Work From Height 6' feet *LOTO <br />SECTION I – WORK AUTHORIZATION <br />Permit Date: ________________________________Cold Work "Complete Section 2" <br />Time Extended To: _______________ AM or PM?*Trenching / Excavation *Refer to ICS Permit form inside HASP <br /> Purged Washed/Rinsed 220-Volt Electricity <br /> Opened and Bled Levels Checked 12-Volt Electricity <br /> Flushed and Cleaned Steamed 110-Volt Electricity <br />SECTION 2 – COLD WORK <br /> Not Applicable <br /> Mechanical <br />PERSONAL PROTECTIVE EQUIPMENT (PPE) <br />Minimum Requirement Additional PPE Additional PPE (Hand)Additional PPE (Body) <br /> Hearing Protection >85 db Metatarsal Guards PVC Gloves Poly Coated <br /> Half Face Respirator Fall Protection Vinyl Gloves FR Coveralls <br /> Hard Hat Goggles Neoprene Gloves Tyvek Disposable <br /> Eye Protection/Glasses Face Shield Nitrile-Disposable Gloves Tychem <br /> Steel Toes Boots Snake Chaps Puncture Proof Welding Clothing (Leathers) <br /> Not Applicable Not Applicable Not Applicable <br /> High Visibility Traffic Vest Disposable Coveralls Latex Gloves FR Rain Suit Standard Rain Suit <br /> Level III Cut Resistant <br />Gloves Welding Helmet 100% Rubber Gloves Chemical Clothing <br />Additional PPE (Respiratory) <br /> Half Face SCBA Organic Vapor Dust/Mist pre-filter and cover <br />Respirator CartridgesRespirator Type <br /> SAR Ammonia <br /> Full Face Escape SCBA Acid Gas HEPA <br /> PAPR Not Applicable Organic Vapor/Acid Gas Combo N-95 <br /> Permit Writer <br />Print Name Signature Work Extension SignaturePersonnel <br />ADDITIONAL SIGNATURES: Additional Permit User Representatives’ Signatures are recorded to certify requirements specified have been <br />communicated. <br /> Permit User(s) <br />Superintendent/Site Safety Officer <br />Competent Person <br />Name:Trades:Date: <br />Name:Trades:Date: <br />Name:Trades:Date: