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Permit to work template for maintenance

Use this checklist as a guide to which equipment or materials should be locked out before any maintenance work. Record and take a photo of the point of isolation. List the precautions, tools, and equipment to be used during the procedure.
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Permit to work template for maintenance

Audit

Scope of Works
Permit valid from
Permit valid to

Isolation/Lock Out/Tagout

Are the following equipment/materials isolated or locked out before any maintenance or installation work:
Electricity
Point of Isolation
Gas
Point of Isolation
Water
Point of Isolation
Air
Point of Isolation
Fire Alarm System
Point of Isolation
Fire Sprinkler System
Point of Isolation

Precautions

Click + to list precautions
Enter details here

Tools and Equipment

Click + to list tools and equipment to be used
Enter details here (e.g. Scaffold, PPE, Welding sets, 110V Tools etc.)

Completion

Full Name and Signature of Contractor Site Supervisor
Full Name and Signature of Client Authorizing Person
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