1. Equipment not in operation
2. All back feeding circuits isolated
3. Control supply switched off
4. Space heater supply switched off
5. Breaker/MCC put off & front opened
6. Breaker racked out
7. Control fuse pulled out
8. Power fuse pulled out
9. Back lid of Breaker panel opened
10. Breaker / MCC internals visually checked
11. Line discharged & Voltage test done
12. Temporary safety ground provided
13. Breaker/ MCC back/front lids closed
14. LOTO performed on Breaker / MCC
Date: Name :
Time: Designation: (Signature)
1