This document is a work permit for working at heights or on fragile roofs. It provides details of the location and duration of work, as well as a list of safety requirements that must be met like using harnesses, ladders, lighting, and having standby attendants. The contractor supervisor and an STL engineer must both sign off to approve the permit and safety plans, and again when closing out the permit to confirm the site is safe.

1. Work Permit for Working on Height / Fragile Roof
Date: ______________
Exact Location: _____________________________________________
Duration of Permit from Date: _________Time_______A.M. / P.M.; to Date: __________Time_____ A.M. / P.M.
WAH / Control No. : ____________Department / Contractor Name: __________________________
Description of Work: __________________________________________________________
Detail Plan Approved: _____________________________________________________________________
Name Of the People Working On Height / Fragile roof
Name Of Attendants ( Stand by person )
Note: People working on height and Stand by person must be trained on working on height.
No
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Item
Proper Lighting / illumination is provided , Good Housekeeping
Helmet with chin strap provided
Full Body Harness with Shock Absorbing twin lanyard provided
Ladder / Scaffolding provided & Inspected
Use of Approved Anchorage Point ensured
Other PPE / equipment as required provided
Horizontal Life Line provided
Vertical Life Line provided
Rope Grab with Lanyard provided
Use of safe walk ladder for roof work
Arrangement for fastening hand tools is made
Tool Box conducted & record available
Safe Access & Egress provided
Yes
No
Not Required
Note: While working, radio / cell phone communication must be available for calling rescue team in case of
emergency, permit stand cancelled in case of emergency
I ……………………………………………………………hereby declare that I have understood the safety requirements explained to
me by responsible person and I shall ensure the full compliance with these requirements by communicating them to
our work force and through continuous monitoring of the work. I undertake the responsibility to carry out the work
safely.
Name & Sign of Contractor supervisor /authorised person: _________________________
Date:______Time:____
Name & Sign of STL Engineer / authorised person: ________________________Date: ______ Time: ________
Extension of permit (after 1st shift closed/sunset) Date: _________________ Time: from __________to _______
Name & Signature of STL Engineer / authorised person: ___________________________
Permit Closure: - I hereby declare that the work is completed/ suspended, all workers under my control have been
withdrawn and the site restored to a safe & tidy condition.
Name & Signature of Contractor Supervisor / authorised person: _______________________Date: ______Time:____
STL / EHS /
Pink – Contractor
Green: STL Engineer
White: STL EHS Dept.