Date of common inspection :
Electrical equipment
De-energized
Locked
Tagged Verified Safe
Floor holes / Work scaffolding protected from falling?
Combustibles :
Protected against heat,flames,sparks
moved away(>10m)
Piping are :
Disconnected
Additional lighting required? : Yes No
Remover permit
Specific Permits required? : No Yes
Hot work permit
Scaffolding permit
(please attach a copy)
Working at hight permit