Hot Work Permit
Job/ Location
CMH 205
Pontotoc
True North
Goose Prairie
Ostrea
Peacock
Date of Permit
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Month
-
Day
Year
Valid From Date
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Month
-
Day
Year
Hot work permit only valid for seven days
Valid to Date
-
Month
-
Day
Year
Hot work permit valid for only seven days
Person Requesting Permit
*
First Name
Last Name
Location of Work:
Job and location within that job.
List name/s of Fire watch/s (Required if there are combustibles within 35 feet of hot work)
Description of work to be performed
*
List who is performing work
*
Work Area Evaluation
Will there be hot work on enclosed containers or old fuel tanks?
*
Yes
No
Containers holding flammable or combustible liquids or gases have been purged, cleaned, and filled with inert liquid or gases and tested for %LEL
Yes
No
N/A
%LEL Reading (at time of test)
%LEL if temperature raises by 10 degrees (warmer temps can cause increased LEL's)
Take picture of work area
Upload image of work area
Hot Work In All Areas
Person completing “Hot Work Permit” understands hazards in the hot work zone.
*
Yes
No
Flame or spark-producing equipment to be used has been inspected and found to be in good repair.
*
Yes
No
Fire extinguishing water hose is in working condition and will remain in service while this work is being done.
*
Yes
No
N/A
Portable fire extinguishers are available, are appropriate for the fire hazard, and personnel have been trained to use them.
*
Yes
No
All combustibles have been relocated 35 feet from the hot work, and the remainder protected with flame-proof curtains or covers.
*
Yes
No
Not possible
All voids and openings leading to other areas (rooms, floors) have been covered.
*
Yes
No
Not possible
All appropriate SOPs and good work practices are being followed.
*
Yes
No
Not Applicable
Do you have the proper personal protective equipment including welding shields, respirators, hearing protection for the job?
*
Yes
No
The method for contacting emergency responders is in place at www.ssandt.solutions under 'Incident Management'.
*
I understand
I do not understand
IF ANY ANSWER IS NO, LIST ALTERNATIVE MEANS OF CONTROL:
Atmospheric monitoring of the work area has been performed for work activities near flammable liquids and gasses or in enclosed areas?
*
Yes
No
N/A
Record initial Atmospheric readings
Periodic atmospheric testing required for work performed near flammable liquids and gasses or in enclosed areas
Time of permit is issued
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Permit received by:
First Name
Last Name
Signature of person receiving the hot work permit.
Job Completion Sign-Off
Work completion time
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
The fire watch verify the area has been monitored for the absence of fire for 30 minutes after Hot work activities have ceased.
Time of final inspection
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12
:
Hour
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10
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30
40
50
Minutes
AM
PM
AM/PM Option
Final Inspection By:
First Name
Last Name
Comments or lessons learned
Signature of person performing final inspection
Construction Manager Name
First Name
Last Name
Construction Manager Approval
Submit
Should be Empty: