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Confined space permit example

Completed permits for common jobs: both sheets, filled in and cancelled. Read one, download it, then issue your own from the blank.

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Confined space permit example

Entering a foul manhole to join a drain

Two people in a 2.4 m manhole, with gas tests, a top person and a winch at the surface.

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What to change

  • Your site and exact location
  • The precautions that do not apply, and why
  • Who issues it and who accepts it

Sources

Checked

  1. Confined Space Entry PermitHollins & Reed Contracting LtdPermit no.HR-0420SiteUnit 3, Canal Side Business ParkExact locationFoul manhole MH2, east yardDetailsContractorValid toIssued toRAMS refValid fromIsolation certHollins & ReedPriya Shah15/10/26 09:0015/10/26 14:00HR-RAMS-10Stopper T1The workSpace and entry pointWork to be doneWhy entry, time limitFoul manhole MH2, 2.4 m deep, 1.2 m across. One entry, the top cover.Join the new drain through the chamber wall. Two to lift the pipe. Make good the benching.The joint cannot be made from the surface. Two entries, 45 minutes each.HazardsOxygen low or highHeatToxic gasDrowningFlammable airRestricted entryEngulfmentPower, machineryPrecautionsDoneBySpace isolated and locked offCleaned, purged and ventilatedAir tested before entry and duringSupervisor and top person namedCommunication agreedRescue plan and equipment readyHarness and lineSafe lighting and toolsBreathing apparatus where neededHow emergency services are calledPriya Shah, tied offReece Ollerton, fan onPriya ShahDan Hollins, Priya ShahRadio and line signalsDan Hollins, drilledBoth entrantsRated for the spaceNot needed. Escape setsPriya Shah, 999What is isolatedHowLockedTagProved byIncoming foul drainStopper at MH1, tied offT1Priya ShahEquipmentGas monitorLightingTripod and winchEscape BARadioOther conditionsOut on any alarm, falling oxygen or a reading moving towards a limit. Our limits CO 20 ppm, H2S 5 ppm, gas 10% LEL.Test oxygen, then gas, then toxics, from the top by probe. Top person stays out. Rescue by winch from the surface.Sign-offNameSignatureDateTimeIssued: precautions checkedAccepted: permit understoodDan Hollinssigned15/10/2608:55Priya Shahsigned15/10/2609:00Worked example of a made-up job. Not a permit. · Page 1 of 2
  2. Confined Space Entry PermitHollins & Reed Contracting LtdPermit no.HR-0420SiteUnit 3, Canal Side Business ParkExact locationFoul manhole MH2, east yardTimeO2 %LEL %CO ppmH2S ppmByGas tests08:4020.8001Priya Shah09:1020.9000Priya Shah09:5020.9000Priya Shah11:0020.8001Priya Shah11:4020.9000Priya ShahPeople in the space: nameCompanyBriefedInOutReece OllertonHollins & Reed09:1509:55Joe PenkethHollins & Reed09:1509:55Reece OllertonHollins & Reed11:0511:45Joe PenkethHollins & Reed11:0511:45CancellationAll out atSpace securedEquipment removed11:45. Both entrants counted out.Cover back on at 12:10. Stopper out at MH1, drain running.Tripod, fan, monitors and lines off the yard by 12:30.HandbackIsolations removedArea returned toNotesStopper T1 removed by Priya Shah at 12:05Thornley Vale Estates Ltd, site keyholderReadings in the job file. Both entrants washed down after each entry.Sign-offNameSignatureDateTimeExtended: new end timeCancelled: area checkedHanded back: area returnedNot extendedDan Hollinssigned15/10/2612:35Dan Hollinssigned15/10/2612:40Worked example of a made-up job. Not a permit. · Page 2 of 2

The same sheet as text

Worked example of a made-up job. Not a permit.

Sheet 1: Confined Space Entry Permit

Hollins & Reed Contracting Ltd

  1. Permit no.HR-0420
  2. SiteUnit 3, Canal Side Business Park
  3. Exact locationFoul manhole MH2, east yard

Details

  1. ContractorHollins & Reed
  2. Issued toPriya Shah
  3. Valid from15/10/26 09:00
  4. Valid to15/10/26 14:00
  5. RAMS refHR-RAMS-10
  6. Isolation certStopper T1

The work

  1. Space and entry pointFoul manhole MH2, 2.4 m deep, 1.2 m across. One entry, the top cover.
  2. Work to be doneJoin the new drain through the chamber wall. Two to lift the pipe. Make good the benching.
  3. Why entry, time limitThe joint cannot be made from the surface. Two entries, 45 minutes each.

Hazards

  1. Oxygen low or highYes
  2. Toxic gasYes
  3. Flammable airYes
  4. EngulfmentYes
  5. HeatNo
  6. DrowningYes
  7. Restricted entryYes
  8. Power, machineryNo

Precautions

  1. Space isolated and locked offDone: yes. By: Priya Shah, tied off
  2. Cleaned, purged and ventilatedDone: yes. By: Reece Ollerton, fan on
  3. Air tested before entry and duringDone: yes. By: Priya Shah
  4. Supervisor and top person namedDone: yes. By: Dan Hollins, Priya Shah
  5. Communication agreedDone: yes. By: Radio and line signals
  6. Rescue plan and equipment readyDone: yes. By: Dan Hollins, drilled
  7. Harness and lineDone: yes. By: Both entrants
  8. Safe lighting and toolsDone: yes. By: Rated for the space
  9. Breathing apparatus where neededDone: no. By: Not needed. Escape sets
  10. How emergency services are calledDone: yes. By: Priya Shah, 999

What is isolated

  1. Incoming foul drainHow: Stopper at MH1, tied off. Locked: no. Tag: T1. Proved by: Priya Shah

Equipment

  1. Gas monitorYes
  2. Tripod and winchYes
  3. Escape BAYes
  4. RadioYes
  5. LightingYes

Other conditions

  1. Out on any alarm, falling oxygen or a reading moving towards a limit. Our limits CO 20 ppm, H2S 5 ppm, gas 10% LEL.
  2. Test oxygen, then gas, then toxics, from the top by probe. Top person stays out. Rescue by winch from the surface.

Sign-off

  1. Issued: precautions checkedName: Dan Hollins. Signature: signed. Date: 15/10/26. Time: 08:55
  2. Accepted: permit understoodName: Priya Shah. Signature: signed. Date: 15/10/26. Time: 09:00

Sheet 2: Confined Space Entry Permit

Hollins & Reed Contracting Ltd

  1. Permit no.HR-0420
  2. SiteUnit 3, Canal Side Business Park
  3. Exact locationFoul manhole MH2, east yard

Gas tests

  1. 08:40O2 %: 20.8. LEL %: 0. CO ppm: 0. H2S ppm: 1. By: Priya Shah
  2. 09:10O2 %: 20.9. LEL %: 0. CO ppm: 0. H2S ppm: 0. By: Priya Shah
  3. 09:50O2 %: 20.9. LEL %: 0. CO ppm: 0. H2S ppm: 0. By: Priya Shah
  4. 11:00O2 %: 20.8. LEL %: 0. CO ppm: 0. H2S ppm: 1. By: Priya Shah
  5. 11:40O2 %: 20.9. LEL %: 0. CO ppm: 0. H2S ppm: 0. By: Priya Shah

People in the space: name

  1. Reece OllertonCompany: Hollins & Reed. Briefed: yes. In: 09:15. Out: 09:55
  2. Joe PenkethCompany: Hollins & Reed. Briefed: yes. In: 09:15. Out: 09:55
  3. Reece OllertonCompany: Hollins & Reed. Briefed: yes. In: 11:05. Out: 11:45
  4. Joe PenkethCompany: Hollins & Reed. Briefed: yes. In: 11:05. Out: 11:45

Cancellation

  1. All out at11:45. Both entrants counted out.
  2. Space securedCover back on at 12:10. Stopper out at MH1, drain running.
  3. Equipment removedTripod, fan, monitors and lines off the yard by 12:30.

Handback

  1. Isolations removedStopper T1 removed by Priya Shah at 12:05
  2. Area returned toThornley Vale Estates Ltd, site keyholder
  3. NotesReadings in the job file. Both entrants washed down after each entry.

Sign-off

  1. Extended: new end timeName: Not extended
  2. Cancelled: area checkedName: Dan Hollins. Signature: signed. Date: 15/10/26. Time: 12:35
  3. Handed back: area returnedName: Dan Hollins. Signature: signed. Date: 15/10/26. Time: 12:40

What a completed permit shows

  • Who issued it and who accepted
  • What was checked first, and what did not apply
  • The record while it ran (fire watch, gas tests, inspections)
  • How it was cancelled and handed back

Two ways to run your permits

On paper, from this book

Print the two sheets, number them and issue one for each job.

Get the blank

Keep the day’s record

Note each permit issued and cancelled in Site Diary, with photos of the area.

Open Site Diary

Permit to work example questions

Are these real permits?

No. Every job, company, person and address here is made up, and so is every reading. They show what goes in each box.

Can I issue one of these as it is?

No. A permit is written for one job, one place, one time. Issue your own from the blank, after checking the place yourself.

What makes a permit invalid?

It covers only the job, the place and the time written on it. If the time runs out or the work changes, stop, then extend it or issue a new one once it is checked as safe. HSE: HSG250.

How long does a hot work fire watch last?

At least an hour of continuous watching after the hot work ends, then at least one more check two hours after the end. HSE: HSG168.

Where is the blank?

On the permit to work template page. Add your logo, then print it or download it.