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: Type : Work at height without guardrails Work at height on fragile surfaces 3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Yes-No-NA Method Statement and Risk Assessment developed, approved and communicated? ☐ ☐ ☐ Area barricaded & proper signage are posted? ☐ ☐ ☐ Qualified and briefed workers? ☐ ☐ ☐ PPE of workers available & inspected as per MS/RA? ☐ ☐ ☐ Tools/Equipment inspected? ☐ ☐ ☐ Safe means of access/ Egress? ☐ ☐ ☐ Lifeline available and inspected? ☐ ☐ ☐ Fragile surface covered / work surface protected? ☐ ☐ ☐ Dimensions of platform and restrain lanyard match safety requirement? ☐ ☐ ☐ Harness with double lanyard provided and its use briefed to workforce? ☐ ☐ ☐ Harness anchorage point checked? ☐ ☐ ☐ Load bearing capacity of anchoring point checked? ☐ ☐ ☐ Load bearing capacity of fragile service checked? ☐ ☐ ☐ Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐ Others ( Specify) ☐ ☐ ☐ 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: 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): 5. Authorization (PM/CM): Name: Designation: Signature: Date /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. WORK AT HEIGHT PERMIT
Page 1 of 2 Form # HSEQ-WHP (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:
Type :
Work at height without guardrails
Work at height on fragile surfaces
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Yes-No-NA
Method Statement and Risk Assessment developed, approved and communicated? ☐ ☐ ☐
Area barricaded & proper signage are posted? ☐ ☐ ☐
Qualified and briefed workers? ☐ ☐ ☐
PPE of workers available & inspected as per MS/RA? ☐ ☐ ☐
Tools/Equipment inspected? ☐ ☐ ☐
Safe means of access/ Egress? ☐ ☐ ☐
Lifeline available and inspected? ☐ ☐ ☐
Fragile surface covered / work surface protected? ☐ ☐ ☐
Dimensions of platform and restrain lanyard match safety requirement? ☐ ☐ ☐
Harness with double lanyard provided and its use briefed to workforce? ☐ ☐ ☐
Harness anchorage point checked? ☐ ☐ ☐
Load bearing capacity of anchoring point checked? ☐ ☐ ☐
Load bearing capacity of fragile service checked? ☐ ☐ ☐
Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐
Others ( Specify) ☐ ☐ ☐

2. WORK AT HEIGHT PERMIT
Page 2 of 2 Form # HSEQ-WHP (Rev 2 - Mar 23)
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: 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):
5. Authorization (PM/CM):
Name: Designation:
Signature: Date /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: