The document is a lift shaft entry permit form outlining project information, permit issuance details, control measures, and acknowledgments needed for safe operations. It requires confirmation of various safety checks and mandates permits for specific high-risk activities. The form also includes sections for authorization and completion verification.

1. LIFT SHAFT ENTRY PERMIT
Page 1 of 2 Form # HSEQ – LSEP (Rev 2 - Mar 23)
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Detail of Surroundings:
Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:
3. Control Measures: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Method statement & Risk assessment developed,
approved & communicated?
☐ ☐ ☐
Availability of rescue procedure and
equipment? ☐ ☐ ☐
Operatives are trained and competent? ☐ ☐ ☐ Workplace appropriately illuminated ☐ ☐ ☐
Any high risk activity associated that requires PTW
(i.e. hot work, CSE)?
☐ ☐ ☐
Forced ventilation provided?
☐ ☐ ☐
Are all necessary Permit approved and displayed at
work location?
☐ ☐ ☐
Means of communication available?
(Mobile, radio etc.)
☐ ☐ ☐
Safe access / Working Platform provided? ☐ ☐ ☐
Mandatory/specific good condition PPEs
are available
☐ ☐ ☐
Availability of barricades/protection to prevent
unauthorized or accidental entry?
☐ ☐ ☐
Life Line provided?
☐ ☐ ☐
Warning signs posted?
☐ ☐ ☐
Fall Protection equipment (e.g. full body
harness) available?
☐ ☐ ☐
Availability of Fall protection arrangement? ☐ ☐ ☐ Other(s): ☐ ☐ ☐
Adequate Lighting provided? ☐ ☐ ☐ ☐ ☐ ☐
4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives,
and I consider them competent to do it safely.
Initiator/Originator
Name:
Designation:
Signature: Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Time
Comments (if any):

2. LIFT SHAFT ENTRY PERMIT
Page 2 of 2 Form # HSEQ – LSEP (Rev 2 - Mar 23)
5. Authorization (PM/CM):
Name: Designation:
Signature: Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time: