Hot Work Permit - Example 2

/ Form 000.653.F0237
Hot Work Permit – Example2
Date: / Start Time: / Time Valid to:
Issued to: / Area:
Describe work to be done:
Equipment No.: / WO No.:
GENERAL PREPARATIONS: (check off all items that apply; supervisor/employee initials each to verify in place)
Initials / Initials
Yes / No / Yes / No
Energy sources locked, tagged, tried / Supervisor has reviewed responsibilities
Radiation shutter locked closed / with fire watch/standby person
Sewers covered, closed, or plugged / Combustible materials removed
LEL monitors provided / Proper fire extinguisher available
LEL Test / % / at / Hrs. / Running water/tarps/blankets
LEL Test / % / at / Hrs. / Signs and barricades posted
LEL Test / % / at / Hrs / Vehicle entry
LEL Test / % / at / Hrs / Other:
Maintenance supervisor approval for / Other:
LEL >0 but <10% / Fire watch/standby person name:
Signs and barricades posted
CONDITIONS NOT ALL MET
Special procedure prepared
PROTECTIVE EQUIPMENT:
First / After / First / After / First / After / First / After
Break / Break / Break / Break / Break / Break / Break / Break
Slicker Suit / Rubber Boot / Chemical Gloves / Face Shield
Goggles / Acid Hood / Full Acid Suit / Cartridge Respirator
Hearing Protection / Breathing Air
APPROVALS (full name):
Hot Work Authorized Permit Issuer / Supervisor / Designated Hot Work Employee
TURN BACK TO OWNER:
Work is not completed: / Date: / Time: / Hrs.:
Status:
Work is completed / Work area has been cleaned
Tools and equipment have been put away / Tags and locks have been removed
Employee/Supervisor / Hot Work Authorized Permit Issuer

Note: This form is referenced in Practice000.653.3101.