SAFE WORK PERMIT CLASS- D RO SR
BLANKET SAFE WORK PERMIT CLASS- D SR. NO. ORIGINAL COPY
FINOLEX INDUSTRIES LIMITED
CAPTIVE POWER PLANT,
GOLAP-RANPAR, RATNAGIRI.MARK (V) WHEREVER APPLICABLE OR (X) WHEREVER NOT APPLICABLE. ORIGINAL COPY SHALL BE KEPT AT THE JOB SITE UNTIL WORK IS COMPLETE.
EXCAVATION, ROAD BLOCKAGE
SWP REQUESTED BY SHRI. _________ SIGN:_________ DEPT. :_______ SWP REQUIRED AT :______ HRS. ON:___________
ESTIMATED DATE OF WORK COMPLETION:_____________ ;
THE WORK TIMING WOULD BE FROM__________ HRS TO__________HRS / 24 HRS.
JOB AT PLANT / DEPT.:_______________ UNIT NO. ____________ LOCATION._______________________________________________________
JOB DESCRIPTION (MENTION THE PURPOSE ALSO) :
A) EXCAVATION :_____________________________________________________________________________________________________________
EQUIPMENT INVOLVED: POWER / HAND TOOL, _____________________________ APPROX. DEPTH _______MTRS.
BACK FILLING DETAILS: ____________________________________________________________________________________________________
B) ROAD BLOCKAGE : (SPECIFY ROAD NO.) _____________________________________________________________________________________
SWP ISSUED ON DATE:_________TIME:____________ HRS. VALID UP TO ___________HRS. ON DATE___________
THE WORK TIMING ALLOWED IS FROM:___________HRS TO:_____________HRS. OR 24 HOURS. ( )
PART 1 : FIRE & SAFETY DEPARTMENTS CLEARANCE:
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED DRAWING OF THE FIRE HYDRANT SYSTEM. ( )
JOB CAN BE PERFORMED SINCE NO FIRE PIPELINE AND EQUIPMENT WOULD BE OBSTRUCTED.
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED DRAWING OF THE FIRE HYDRANT SYSTEM, ( )
AND SINCE FIRE PIPE LINE AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE PERFORMED WITH
EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: ___________________________________________________________
____________________________________________________________________________________________________________________
SINCE ROAD NOS_______ WOULD BE BLOCKED ALTERNATIVE ROUTE NO.__________ FOR EMERGENCY MANAGEMENT WOULD BE UTILISED, IF REQUIRED. ALL THE DETAILS NOTED AND INFORMED TO F & S STAFF.
SHIFT IN CHARGE FIRE & SAFETY: SIGN:______________NAME:___________________________DATE:___________TIME:__________HRS
PART 2 : ELECTRICAL DEPARTMENTS CLEARANCE:
CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED ELECTRICAL AND TELEPHONE CABLES ( )
NETWORK DRAWING. JOB CAN BE PERFORMED SINCE NO ELECTRICAL AND TELEPHONE CABLES AND EQUIPMENT
WOULD BE OBSTRUCTED.
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED ELECTRICAL AND TELEPHONE CABLES ( )
NETWORK DRAWING. SINCE THE NETWORK AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE
PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: _______________________________________
___________________________________________________________________________________________________________________
SHIFT IN CHARGE ELECTRICAL DEPT: SIGN:___________NAME:___________________________DATE____________TIME:_________HRS
PART 3 : INSTRUMENTATION DEPARTMENTS CLEARANCE:
CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED INSTRUMENTATION CABLE NETWORK ( )
DRAWING. JOB CAN BE PERFORMED SINCE NO INSTRUMENTATION CABLES WOULD BE OBSTRUCTED.
- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED INSTRUMENTATION CABLES NETWORK ( )
DRAWING AND SINCE THE NETWORK AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE
PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS:_____________________________________________
___________ ____________________________________________________________________________________________________________
SHIFT IN CHARGE INSTRUMENTATION DEPT: SIGN:______________NAME:__________________DATE____________TIME:_________HRS
PART 4: CONSTRUCTION DEPARTMENTS. CLEARANCE:
- CHECKED THE PROPOSED AREA OF EXCAVATION, SURROUNDING BUILDING AND STRUCTURE AND UNDERGROUND ( )
PIPELINES. JOB SHOULD BE PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: __________________
_________________________________________________________________________________________________________________________
ENGINEER CONSTRUCTION DEPT. : SIGN:__________________NAME:_________________________DATE____________TIME:_________HRS
PART 5 : AREA INCHARGES CLEARANCE :
PERMITTED EXCAVATION DEPTH:___________ MTRS INFORMED TO SECURITY ( )
BARICADING DETAILS: ______________________________________________________________________________________________________
BACK FILLING DETAILS:_____________________________________________________________________________________________________
SPECIFIC INSTRUCTIONS (if any) : ____________________________________________________________________________________________
SAFE WORK PERMIT IS ISSUED AFTER CONSIDERING ALL SAFETY ASPECTS & ADOPTING NECESSARY SAFETY PRECAUTIONS AND WILL BE EXECUTED BY ADOPTING SAFE WORK PROCEDURE. THE JOB, SAFE METHOD OF WORK, USE OF PPE, HOUSE KEEPING, EMERGENCY PREPAREDNESS & RESPONSE PROCEDURE, COMMUNICATION MEDIA ETC ARE CLEARLY EXPLAINED TO THE EXECUTING STAFF.
NAME OF SAFETY WATCH: SHRI______________________
Sign : ______________ NAME:__________________
DATE:________________ TIME :__________________HRS.
AUTHORISED Operations satisfaction
Sign : _____________ NAME:___________________
DATE : ______________ time:___________________HRS.
AUTHORISED MaintENANCE SATISFaction
SHIFTWISE CHECKING OF SPECIFIED CONDITIONS MENTIONED OVERLEAF SWP FOR CONTINUATION OF JOB.
SR. NO. DATESHIFTNAME OF
SAFETY WATCHOPERATIONS SATISFACTION
SIGNATURE NAME
MAITENANCE SATISFACTION
SIGNATURE NAME
AFTER ANY EMERGENCY OR STOPPAGE OF WORK FOR CERTAIN REASON ALL THE PARAMETERS OF THE SWP ARE RECHECKED AND SINCE FOUND SATISFACTORY RESTART OF THE JOB IS ALLOWED AND ENTRIES MADE.
JOB STOPPED FOR REASON : ----------------------------------------------------------ON AT : HRS.
SR. NO.DATESHIFTTIMEMAINTENANCE SATISFACTIONOPERATIONS SATISFACTION
SIGNATURE NAMESIGNATURE NAME
HANDING OVER
THE JOB IS COMPLETED [ ]
THE JOB IS INCOMPLETE. [ ]
BACK FILLING DONE AS INSTRUCTED. [ ]
BARICADING REMOVED. [ ]
HOUSE KEEPING DONE. [ ]
PERMIT RETURNED.
SIGN :____________NAME :______________
DATE : __________ TIME :_______________HRS.
AUTHORISED MaintENANCE SATISFactionTAKING OVER
WORK CHECKED. [ ]
HOUSEKEEPING DONE IS SATISFACTORY. [ ]
ROAD BLOCKAGE REMOVED, INFORMED [ ]
TO FIRE CONTROL ROOM AND SECURITY
WORK ACCEPTED
SIGN : ___________ NAME:________________
DATE____________ TIME :_________________HRS.
AUTHORISED OPERATIONS SATISFACTION
NOTE: THE PERMIT IS NOT VALID IN THE EVENT OF AN EMERGENCY. HOWEVER AFTER THE EMERGENCY IS OVER IT CAN BE REVIVED AFTER RECHECKING OF ALL THE CONDITIONS MENTIONED OVERLEAF AND THEN SUBSEQUENT CERTIFICATION OF THE SAME BY SIGNING FOR OPERATIONS SATISFACTION AND MAINTENANCE SATISFACTION. THE PERMIT IS VALID ONLY FOR THE PERIOD AND DURATION MENTIONED. ON EXPIRY OF VALIDITY NO EXTENSION IS PERMISSIBLE.
OVER NIN CASE, ELECTRICAL POWER TO BE ISOLATED/ RESTORED, THEN ELECTRICAL LOCK-
OUT/ LIFT-OUT (CLASS-E) PERMIT MUST BE ACCOMPANIED WITH THIS PERMIT. MASTER CARD IS A MUST FOR VESSEL
ENTRY ONLY.
(for extension pl. see over leaf )
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