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): 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:

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: