This cold work permit document is a 2-page form used to request and approve cold work. It lists the job location and description, tools and materials used, potential hazards, precautions needed, and protective equipment. The form requires signatures from the permit requester, acceptor, issuer, and other parties to hand over responsibility between shifts, declare work completion, ensure the site is left safely, and sign off and cancel the permit.

1. COLD WORK PERMIT
Page 1 of 2 Form # HSEQ- CWP (Rev 2 – Mar 23)
Issue Date: _______________ Permit No: ____________
Permit Requested By: __________________ Company Name: ________________
Permit Accepted By: __________________ Company Name: ________________
Validity From: __________ To: __________
1. Job Location: _____________________________________________________________
2. Job Description: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
3 Tools & Materials to be used:
❑Explosive Device ❑Sandblaster ❑Jack hammers
❑Hand Tools ❑Drill ❑Jack hammers
❑Powered Excavation Equipment ❑Powered cutting Saw ❑Ladder/Scaffolding
❑Air Heater ❑LPG Gas ❑Others
4- Details of potential hazards:
❑Falling from height ❑ Material Fall down ❑Skin Exposures
❑Electrocuted ❑ Slip and trip ❑Burn out due to fire/acid etc.
❑Exposure to Eye ❑ Inhalation of any Gas ❑Breathing Problem ❑Others
5- Details of precaution need to be taken:
❑Caution Signage to be placed ❑Proper fixture an erection of Scaffolding/Ladder
❑Excavated Area fencing ❑Electrical Isolation
❑Fire water supply isolation ❑Fire water tanker to be provided
❑Fire Extinguishers to be provided ❑Exhaust fan to be provided
❑Informed security Et Help Desk ❑Other
6- Details of protective equipment to be used or worn:
❑Safety Shoes
❑Safety Helmet
❑Face Shield/Goggle/Glasses
❑Gloves (As per work)
❑Safety harness/Belt/Lifeline
❑Uniform
❑Respiratory Equipment/Dust Mask
❑Chemical Suite/Apron
❑Ear protection
❑Fire Blanket/Protection Sheet
❑Rubber Mat/Ground Fault Interrupter
❑Other
7- Signature of Permit Requestor:
Contact No:-
8- Signature of PTW Acceptor:
Contact No:-
9- Signature of Permit Issuer/HSE Representative:

2. COLD WORK PERMIT
Page 2 of 2 Form # HSEQ- CWP (Rev 2 – Mar 23)
10- Signature of handover of responsibility between shifts, if needed.
11- Declaration by competent person in -charge of work that work is completed.
12- Signature of Maintenance / works representative ensuring that the work is
completed, site has been checked and that equipment and place may be reinstated / left
Safely isolated.
13- Signature of person issuing the permit / HSE representative which confirms that the
Site has been left in safe condition and the permit is cancelled.
14- Signature of the management representative signing off the permit to work.
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