热，冷，限制空间，特殊作业许可证格式

PermitNo.:CWP-RigNo.:WellNo.:Date:Timestarts:Timepermitexpire:AreatoBeWorkedOn:SpecificWorktoBeDone:PermitApplicant&CrewMenbers:DescriptionofWork(s):SpotCheck(ConductedbyPIC):Signature:Time:Anyspecialrequirementsandequipmentsplacean"√"ifrequiredorleaveblankifnotrequired.oPre-JobSafetyMeetingHeld(JSAReviewed)oNon-EssentialPersonnelClearedFromAreaoLockout/TagoutRequired:BreakerSwitch#oManRiderJSACompleted/Communicatedo PoweroffVerifiedBy:o AllToolsSecuredToWorkso WillLockoutRemainPastyourShift?Lock#o Ladders/ScaffoldingRequiredo EquipmentDepressurizedo SignalsDiscussed(Verbal&HandorRescueline)o EquipmentDrainedo FullBodyHamess/Lanyard/RopeRequiredo FlushedWithWatero FireExtinguisherReadyTouseo SteamedOuto IntrinsicallySafeToolRequiredo Vessels/LinesPurged/WithWhat?o ExplosionProofExectricalCordsRequiredo Drains/SumpsCovered&Sealedo ExectricalToolsGroundedTypeo Equipmentcooled/Ventilated/Isolatedo Fire&GasDetectorsIsolatedo CombustibleMaterialRemovedo AreaBarriers/SignsPlacedo Blindsinstalled&BleedsOpeno Water/SteamHouseReadyToUseo Vessels/LinesToBeVentedo FaceShield/GogglesRequired(CircleOne)o PhysicalSeparationReqiuredo HearingProtectionRequiredo Grounding/BondingCablesRequiredo FireBlanketRequiredo ExplosiveOrToxicGasMonitoringo Non-StandardPPEClothing(Type)?o OxygenDeficiencyTestRequiredo RuberSafetyBootsRequiredo StandbyManRequiredo ParticalDustMaskRequiredo IntrinsicallySafeLightsRequiredo ChemicalCartridgeRespiratorRequiredo IntrinsicallySafeRadioRequiredo OxygenVentilatorRequiredo NoTransmittingDevices(Radios,Mobiles,Paper)o SCBARequiredo SafeEscapeRoutesFromWorkAreaIdentifiedo SABARequiredo RestrictedWorkBelowRequiredo Install,Inspect&Operate3rdPartyContractorEquipmento StandbyVesselNotifiedo PAAnnouncementPriorToStartingJobo FallProtectionEquipmentRequired&Inspectedo MSDSReviewedWithAppropriatePersonnelTakeAppropriateActionsBasedOnThePrecautionsNotedAbove!!!CommentsandAdditionalRequireds:GasTestingRecordsGasTestPerformedBy(Name):AgentLimit(s)ResultTimeSignatureAgentLimit(s)ResultTimeSignatureOxygen19.5-23%Oxygen19.5-23%Flammable﹤10%LELFlammable﹤10%LELH2S﹤10ppmH2S﹤10ppmPTWSignaturePTWIssuer(sign):PTWReceiver(sign):StopWork&CancelPermitsReason:Signature:Time:PTWClosedo Completedo SuspendedPTWReceiver(sign):o TimeOuto PermitCancelledPTWIssuer(sign):PermitNo.许可证号:RigNo钻机号:WellNo井号:Date日期:TimeStarts开始时间：TimeExpires结束时间：AreatoBeWorkedOn工作区域:SpecificWorktoBeDone具体工作:PermitApplicant&CrewMenber许可证申请人或班组人员:DescriptionofWork(s)工作描述:SpotCheck(ConductedbyPIC)检查现场的负责人:Signature签名:Time时间:Foranyspecialrequirementsandequipment,placean"√"ifrequiredorleaveblankifnotrequired.对于特殊的要求和设备,如果需要则打"√",不需要则留空。oPre-JobSafetyMeetingHeld(JSAReviewed)召开班前安全会(审核作业安全分析)oNon-EssentialPersonnelClearedFromArea无关人员是否离开现场oLockout/TagoutRequired:BreakerSwitch锁定和 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:断路开关oManRiderJSACompleted/Communicated是否进行了载人装置的作业安全分析,通知相关人员?o PoweroffVerifiedBy电源切断检验者:o AllToolsSecuredToWork所有工具固定到位o WillLockoutRemainPastyourShift?Lock锁定延至下一班?锁定o Ladders/ScaffoldingRequired所需的梯子和脚手架o EquipmentDepressurized设备压力被释放o SignalsDiscussed(Verbal&HandorRescueLine)是否讨论过信号(语言,手势或逃生路线)o EquipmentDrained设备排水o FullBodyHarness/Lanyard/RopeRequired是否需要全身式安全绳/系索或绳索o FlushedWithWater用水冲洗o FireExtinguisherReadyToUse灭火器是否随时待用o SteamedOut排出蒸气o IntrinsicallySafeToolRequired是否需要基本的安全工具o Vessels/LinesPurgedwithWhat?容器和管线用何物清洗？o ExplosionProofExectricalCordsRequired是否需要使用防爆电缆o Drains/SumpsCovered&Sealed排水渠/污水沟盖住或封住o ExectricalToolsGroundedType电动工具是否接地o Equipmentcooled/Ventilated/Isolated设备冷却/通风/隔离o Fire&GasDetectorsIsolated火灾和气体检测仪隔开o CombustibleMaterialRemoved可燃材料是否移走o AreaBarriers/SignsPlaced工作区放置隔离装置或警示标志o Blindsinstalled&BleedsOpen安装盲板并打开泄孔o Water/SteamHouseReadyToUse水房和蒸气房随时可用o Vessels/LinesToBeVented容器和管线被通风o FaceShield/GogglesRequired(CircleOne)是否需要面罩/护目镜(圆形)o PhysicalSeparationReqiured是否需要物理隔离o HearingProtectionRequired是否需要听力保护装置o Grounding/BondingCablesRequired是否需要接地和搭接电缆o FireBlanketRequired是否需要防火毯o ExplosiveOrToxicGasMonitoring是否监测爆炸或有毒气体o Non-StandardPPEClothing(Type)?是否有不规范的劳保服(类型)?o OxygenDeficiencyTestRequired是否需要进行缺氧测试o RubberSafetyBootsRequired是否需要橡胶安全靴o StandbyManRequired是否需要人员待命o ParticalDustMaskRequired是否需要防尘口罩o IntrinsicallySafeLightsRequired是否需要基本的安全灯o ChemicalCartridgeRespiratorRequired是否需要化学药品呼吸器o IntrinsicallySafeRadioRequired是否需要基本的无线电通讯装置o OxygenVentilatorRequired是否需要氧气呼吸器o NoTransmittingDevices(Radios,Mobiles,Paper)是否无发射装置(收音机,手机和呼机)o SCBARequired是否需要正压式呼吸器o SafeEscapeRoutesFromWorkAreaIdentified是否确定了工作区的安全逃生路线o SABARequired是否需要供气式呼吸器o RestrictedWorkBelowRequirement限制性工作低于要求o Install,Inspect&Operatethe3rdPartyContractorEquipment是否安装、检查和操作第三方的设备o StandbyVesselNotified是否指定了备用容器o PAAnnouncementPriorToStartingJob在开始工作前时间PA通知o FallProtectionEquipmentRequired&Inspected是否需要防坠落保护装置,检查过了吗?o MSDSReviewedWithAppropriatePersonnel相关人员是否检查了材料安全数据表TakeAppropriateActionsBasedOnThePrecautionsNotedAbove!!根据上述内容采取有效 措施 《全国民用建筑工程设计技术措施》规划•建筑•景观全国民用建筑工程设计技术措施》规划•建筑•景观软件质量保证措施下载工地伤害及预防措施下载关于贯彻落实的具体措施 !!CommentsandAdditionalRequirements说明和其它要求:GasTestingRecords气体测式 记录 混凝土 养护记录下载土方回填监理旁站记录免费下载集备记录下载集备记录下载集备记录下载 GasTestPerformedBy(Name)气体测试人:Agent介质Limit(s)极限Result结果Time时间Signature签名Agent介质Limit(s)极限Result结果Time时间Signature签名Oxygen氧气19.5-23%Oxygen氧气19.5-23%Flammable可燃物﹤10%LELFlammable可燃物﹤10%LELH2S﹤10ppmH2S﹤10ppmPTWSignature工作许可证签名PTWIssuer(sign)工作许可证签发人（签字）:PTWReceiver(sign)工作许可证接收人（签字）:StopWork&CancelPermit停止工作和取消许可证Reason原因:Signature签字:Time时间:PTWClosed工作许可证关闭o Completed完成o Suspended中止PTWReceiver(sign)许可证接受人（签字）:o TimeOut时间到o PermitCancelled许可证取消PTWIssuer(sign)许可证签发人（签字）: