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    Heavy Equipment Operation Permit Form

    Uploaded by

    Armando Aballe
    This heavy equipment operation permit form contains information about operating heavy equipment at a work site. It requires details about the requestor, equipment type, operator qualifications, work description, hazards, controls, and approvals. The form is used to document compliance with safety requirements for equipment operation and to get necessary sign-offs before starting work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Heavy Equipment Operation Permit Form

    Uploaded by

    Armando Aballe
    93 views1 page
    This heavy equipment operation permit form contains information about operating heavy equipment at a work site. It requires details about the requestor, equipment type, operator qualifications, work description, hazards, controls, and approvals. The form is used to document compliance with safety requirements for equipment operation and to get necessary sign-offs before starting work.

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This heavy equipment operation permit form contains information about operating heavy equipment at a work site. It requires details about the requestor, equipment type, operator qualifications, work description, hazards, controls, and approvals. The form is used to document compliance with safety requirements for equipment operation and to get necessary sign-offs before starting work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    93 views1 page

    Heavy Equipment Operation Permit Form

    Uploaded by

    Armando Aballe
    This heavy equipment operation permit form contains information about operating heavy equipment at a work site. It requires details about the requestor, equipment type, operator qualifications, work description, hazards, controls, and approvals. The form is used to document compliance with safety requirements for equipment operation and to get necessary sign-offs before starting work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    HEAVY EQUIPMENT OPERATION PERMIT FORM

    NAME OF REQUESTOR PERMIT NUMBER:


    DATE REQUESTED START DATE: END DATE:
    POSITION START TIME: END TIME:
    I. TO BE COMPLETED BY THE REQUESTOR
    Description of the work to be performed: ________________________________________________________________________________
    Work location: ____________________________________________________________________________________________________
    II. Type of heavy equipment
    Bulldozer Road grader Forklift Wheeled tractor - Scraper
    Loader Mobile crane Dump truck Boom Truck
    Backhoe Roller Compactor Others pls specify: _______________________________
    III. To be completed by the qualified person doing the work: (Use another sheet if necessary)
    VI . Personel in charge of heavy
    DESIGNATION SIGNATURE QUALIFIED
    equipment operation
    1 Operator's name _______________ ______________________ _____________ oY oN oN/A
    2 Spotter's name ______________ ______________________ _____________ oY oN oN/A
    V. Nature of work VI. PPE requirement VII. Safety equipment
    o Construction works (road works, asphalt paving,
    o Hard hat o Safety warning signages
    demolition, renovation, formworks)
    o Plant facility repair or maintenance o Safety Shoes o First Aid Kit and Equipment
    o Others please specify: ________________________ o Reflectorized Vest o Others: ______________________________
    VIII. Hazards Shift 1 Shift 2 Shift 3 Shift 4 Shift 5
    1. unskilled and untrained spotter oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A

    2. uncertified operator oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A

    3.. unmaintained heavy equipment oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A

    4. falling materials and equipment oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A

    5. Impaired vision of operator oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A


    6. struck by or pinned down by heavy
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    equipment
    6.contact with underground or overhead
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    utilities
    7.Other hazards related to use of heavy
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    equipment pls. specify:______
    IX. Controls Shift 1 Shift 2 Shift 3 Shift 4 Shift 5
    1.provide training from DOLE accredited
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    training organization
    2.operator shall conduct daily visual
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    inspection and annual testing from
    3.Isolate the area and prohibit
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    unauthorized entry
    4. Appoint a trained spotter oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    5.Perform eye check-up. Operator should
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    have 20/20 vision
    6.Observe safety requirements in
    avoidance of danger in underground oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    utilities standards
    7.Control measure in place to address
    oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A oY oN oN/A
    specific hazards:_________________
    Note: If the hazard is present in the area, check YES and provide necessary safety control measure.
    Remarks:

    I have reviewed the work authorized by this permit and the information pertining to each item. Safety proedures have been put in place and are
    understood by all personnel.
    X. Approval(s) to perform the work

    Prepared by: Prepared by: Prepared by: Prepared by: Prepared by:
    ______________ ______________ ______________ ______________ ______________
    Safety Officer Safety Officer Safety Officer Safety Officer Safety Officer

    Approved by: Approved by: Approved by: Approved by: Approved by:
    _______________ _______________ _______________ _______________ _______________
    Site Manager Site Manager Site Manager Site Manager Site Manager
    Date: Date: Date: Date: Date:

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