OFF HOURS WORK PERMIT

Project Name
Project Number:
Ask the PCL/ED Superintendent.
Start Date(s) of Work:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmultiple dates can only be used for one week maximum
To
End Date(s) of Work:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmultiple dates can only be used for one week maximum
During this Off Hours Work Permit, the undersigned as the Designated Supervisor must be a Competent Person as set out in the Ontario Health and Safety Act and agrees to the following (check each box)
Description of Work

Enter in full sentences without bullet points/separate lines.0/282
Hazard ID and Review

Enter in full sentences without bullet points/separate lines.0/301
Projected Hours of Work: From

Hour Minutes

AM/PM Option
Projected Hours of Work: To

Hour Minutes

AM/PM Option
Company
Name cannot contain any of the following special characters: * ? / \ : < > " |
Applicant's Name
Applicant's Signature
Designated Supervisor's Name
Designated Supervisor's Signature
Designated Supervisor Cell Number

NAMES OF WORKERS - all workers must be listed.

*A copy of this permit is to be submitted to PCL/ED and another copy kept with the crew for the duration of the shift*
Work with the PCL/ED Superintendent to fill out the following section.
PCL/ED Superintendent (Name)
PCL/ED Superintendent (Signature)
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PCL/ED Primary Contact

Rows Name Phone Number

PCL/ED Primary Contact
Site Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Rows	Name	Phone Number
PCL/ED Primary Contact

PCL/ED Alternative Contact

*All incidents must be reported immediately to PCL/ED*

In case of emergency, call 911
Email Address?
A copy of the permit will be sent here.
Should be Empty:

*A copy of this permit is to be submitted to PCL/ED and another copy kept with the crew for the duration of the shift*