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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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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:
Point of Isolation
Point of Isolation
Point of Isolation
Point of Isolation
Fire Alarm System
Point of Isolation
Fire Sprinkler System
Point of Isolation
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.)
Full Name and Signature of Contractor Site Supervisor
Full Name and Signature of Client Authorizing Person
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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