Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0001

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0002

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0003

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0004

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0005

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0006

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0007

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0008

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0009

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0010

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0011

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0012

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0013

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0014

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0015

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0016

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0017

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0018

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0019

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0020

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0021

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0022

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0023

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0024

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0025

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0026

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0027

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0028

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0029

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0030

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0031

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0032

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0033

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0034

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0035

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0036

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0037

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0038

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0039

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0040

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0041

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0042

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0043

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0044

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0045

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0046

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0047

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0048

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0049

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0050

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0051

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0052

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0053

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0054

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0055

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0056

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0057

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0058

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0059

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0060

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0061

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0062

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0063

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0064

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0065

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0066

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0067

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0068

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0069

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0070

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0071

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0072

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0073

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0074

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0075

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0076

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0077

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0078

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0079

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0080

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0081

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0082

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0083

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0084

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0085

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0086

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0087

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0088

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0089

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0090

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0091

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0092

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0093

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0094

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0095

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0096

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0097

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0098

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0099

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date:

Top Copy : Permit Issuer, Middle Copy : Security, Bottom Copy : Permit Acceptor

HOT WORK PERMIT

REF:

Contractor:

Permit Acceptor:

Mobile Number:

Building:

Floor Number:

Corridor:

0100

Room Number(s):

Job Details:

Has a suitable and sufficient risk assessment been undertaken for this task?

YES

NO

Has a method statement been undertaken for this task?

YES

NO

NB: The Management of Health and Safety at Work Regulations 1999 (as amended) require that organisations with five or more employees record the significant findings of assessments and identify those especially at risk. Risk assessments and method statements must be submitted to Estates & Capital Development Department in advance of works commencing.

PRECAUTIONS - A smoke/heat detector isolation permit MAY be required. - A Confined Space permit MAY be required. - Security Control WILL be informed by the Contractor prior to commencement of the work either in person or by telephone on 0121 204 4803. - All hot work WILL be carried out by appropriately trained and competent persons. - Appropriate fire extinguishers WILL be made available near to the work area. The Contractor WILL supply their own extinguisher(s) for this purpose. - Persons undertaking the work WILL be familiar with the nearest means of escape and method of raising the alarm in case of fire. - Where possible, combustible materials WILL be removed from the area, or otherwise suitably protected. - All adjacent openings WILL be protected against the possibility of smoke, fume or sparks passing through them. - All equipment used in hot work WILL be in good order with any cylinders being appropriately secured. The area WILL be monitored throughout the work and inspected after completion of hot works at the interval specified below:

20 mins

60 mins

120 mins

EMERGENCY CONTACT (Person not involved in the work) Name:

Position:

Contact:

AUTHORISATION AND ACCEPTANCE I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the conditions of this authorisation form have been explained to all workers involved. I accept responsibility for this work. Permit Acceptor:

Signature:

Valid From:

Time:

Date:

Company:

Permit Issuer:

Valid To:

Time:

Date:

HANDBACK, RECEIPT AND CANCELLATION I confirm that the activity has been completed, checked by myself and the area left secure and in a safe and tidy condition. Signature:

Permit Acceptor:

Time:

Date:

SECURITY

ESTATES & CAPITAL DEVELOPMENT

I acknowledge receipt of this permit having been informed that the person in charge has left the area secure and in a safe and tidy condition.

I am satisfied that the activity has been completed in accordance with this permit and the area left secure and in a safe and tidy condition.

Time:

Date:

Time:

Date: