The document outlines a lifting work permit form that must be filled out by the initiator, detailing project information, permit issuance details, and lifting operation specifics. It emphasizes safety checks, risk assessments, and the necessary certification for cranes and lifting gear. Acknowledgment sections for initiators and evaluators ensure compliance with safety measures before the lifting operation commences.

1. LIFTING WORK PERMIT
Page 1 of 2 Form # HSEQ-LWP (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:
Weight of Load : Max Height of Lift:
Max. Radius of Lift: Lifting Equipment ID/Registration No.:
Crane Capacity (SWL)
Lift shall not be carried out if the load chart capacity
exceeds 80% (Capacity …………)
Lifting Point Defined: ☐ Yes ☐ No Road Closure/ Isolation required: ☐ Yes ☐ No
Underground services identified (if applicable):
☐ Yes ☐ No
Load Centre of Gravity Calculated: ☐ Yes ☐ No
3. Lifting Operation Details: (To be filled by initiator/originator)
Crane Operator Contact:
Rigger-1 Contact:
Rigger-2 Contact:
Type of Lifting Crane: ☐ Mobile Crane
☐ Wheel crane ☐ Crawler Crane
☐ All Terrain
☐ Loader/Hiab Crane
☐ Excavator
☐ Elevated working Platform
☐ Mobile Concrete Pump
☐ All Winch
☐ Other :
Lifting Crane Specification: ☐ Year of make (<25 years): __________
☐ Lifting Capacity: __________
☐ No. of rope fall wraps: ___________
☐ SWL: ______________
☐ Boom Reach: __________
☐ Fly Jib Reach: ___________
☐ Other(s): _____________
Type of lifting Gear(s): ☐ Chain Sling,
No. Of Legs: ___________
Each Leg Capacity: ____________
SWL: ______________
☐ Webbing Sling, SWL: ____________
☐ Wire Rope, SWL: _____________
☐ Lifting Beam, SWL: ___________
☐ Shackle, SWL: _____________
☐ Chain Blocks, SWL: ____________
☐ Hook with latch, SWL: ___________
☐ Eye Bolt/Nut, SWL: ____________
☐ Other(s): _________________

2. LIFTING WORK PERMIT
Page 2 of 2 Form # HSEQ-LWP (Rev 2 - Mar 23)
4. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Risk assessment/ method statement and Lifting
Plan developed, approved and communicated?
☐ ☐ ☐
Crane outriggers fully extended and
spreading pads in place
☐ ☐ ☐
Operatives are consulted and trained? ☐ ☐ ☐ All wheels are off the ground. ☐ ☐ ☐
Provision of vigilance supervision? ☐ ☐ ☐
SWL and radius indicators in working order
with visual and audible warning
☐ ☐ ☐
Has the crane valid certification ☐ ☐ ☐ Wind indicator is fitted & in working order ☐ ☐ ☐
Has the lifting gears valid certification ☐ ☐ ☐
load(s) slung correctly by a competent
rigger
☐ ☐ ☐
Riggers/slinger competent and certified ☐ ☐ ☐ Tag-line(s) are connected with the load ☐ ☐ ☐
Correct crane selected for the load(s) and radius ☐ ☐ ☐
Suspended Load slewing path is cleared
from people and barricaded
☐ ☐ ☐
Ground suitable, even, firm and prepared ☐ ☐ ☐
Destination of load(s) is cleared and
prepared sufficiently
☐ ☐ ☐
Safe means of access/egress provided? ☐ ☐ ☐ Load rating chart for the crane is available ☐ ☐ ☐
Crane is set-up away from excavation ☐ ☐ ☐ Communication aid available (radio device) ☐ ☐ ☐
Crane swing radius area is free from overhead
cable/ structure or other cranes
☐ ☐ ☐
Has the operator have a valid 3rd
party
certificate and license?
☐ ☐ ☐
Proper barricade and signage are posted? ☐ ☐ ☐ Others (specify): ☐ ☐ ☐
5. 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: Date /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: Date /Time
Comments (if any):
6. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
7. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator: Designation:
Signature: Date /Time
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator: Designation:
Signature: Date /Time