Confined Space Entry Permit Example
Example document for Confined Space Entry Permit. Use this as a reference when creating your own.
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Document: Confined Space Entry Permit
Example Document
Last updated 7/27/2026
Confined Space Entry Permit
1. Permit Details
Permit Number: CS-2023-045 Date of Issue: 15/10/2023 Time of Issue: 07:30 AM Valid Until: 15/10/2023 03:30 PM
2. Location and Description of Work
Company Name: Apex Plumbing Services Pty Ltd Site Address: 123 Smith St, Parramatta, NSW, 2150
Description of Confined Space: Underground concrete stormwater pit
Specific Location: South-East carpark, adjacent to building entry
Work to be Done: Removal of heavy silt build-up and debris extraction using vacuum truck.
3. Hazard Identification
Potential Hazards (Check all that apply):
- Oxygen deficiency or enrichment
- Flammable atmosphere
- Toxic gases or vapours
- Engulfment (liquid or solid)
- Mechanical / Electrical hazards
- Noise / Vibration
- Temperature extremes
- Biological hazards
- Other:
4. Risk Control Measures
Atmospheric Testing (Results MUST be recorded before entry):
- Oxygen: 20.8% (Safe range 19.5% - 23.5%)
- Flammable Gas: 0% LEL (Safe range 0% - 10% LEL)
- Toxic Gas: H2S 0 ppm
- Time of Test: 07:15 AM
- Test Equipment Serial No: GAS-TEK-99
Isolation / Lock Out Tag Out (LOTO):
- Electrical isolation (Lock/Tag applied) - Sump pump isolated.
- Mechanical isolation (Lock/Tag applied)
- Pipe isolation (Blind/Blank installed)
- Other isolation - Traffic cones and bollards around pit opening.
Ventilation:
- Natural ventilation
- Mechanical ventilation (Extraction/Supply) - Blower fan running.
Personal Protective Equipment (PPE) Required:
- Safety Helmet
- Safety Boots
- High Visibility Clothing
- Safety Glasses / Goggles
- Hearing Protection
- Respiratory Protection (Type: )
- Harness (Fall Arrest)
- Lifeline attached
- Gloves (Type: Rubber)
- Other:
5. Entry Personnel
Authorised Entrants (Names & Signatures):
| Name | ID No. | Time In | Time Out | Signature |
|---|---|---|---|---|
| J. Smith | 55432 | 08:00 | 10:00 | J. Smith |
| M. Brown | 88721 | 08:00 | 10:00 | M. Brown |
Standby Person:
- Name: D. Lee
- Location: Top of ladder, 2 meters from edge.
- Communication Method: Two-way radio and visual contact.
- Emergency Contact Number: 000
6. Emergency Procedures
Emergency Rescue Plan Attached: [x] Yes [ ] No
Rescue Equipment Available (Check all that apply):
- Tripod and winch
- Full body harness
- Lifelines
- Breathing apparatus (SCBA)
- First aid kit
- Fire extinguisher
7. Acknowledgement and Sign-off
I acknowledge that I have read and understood the contents of this permit and the associated risk assessment. I agree to comply with all safety controls listed.
Authorised Entrant Signatures:
- J. Smith
- M. Brown
Issuer Declaration: I confirm that all necessary isolations have been made, atmosphere is safe, and control measures are in place.
Issuer Name: Sarah Jenkins Position: Site Supervisor Signature: S. Jenkins
Cancellation / Extension: This permit is cancelled at: 10:15 AM on 15/10/2023 Reason: Work completed early. Atmosphere tested clear post-work.
Cancelled By: Sarah Jenkins [Signature]
Notes
This example shows a typical permit for a plumbing crew cleaning a pit. Note the specific oxygen reading of 20.8%, which is normal. The permit lists the specific isolation of the sump pump. Two entrants are listed, which requires a specific rescue plan for two people. The permit was cancelled when work finished early, which is best practice to ensure the permit timeframe matches the actual work time.
About this Example
Part of the Confined Space Entry Permit document collection
Document Type
Confined Space Entry Permit
A legal document required before anyone enters a confined space to work. It ensures risks are managed and safety procedures are followed.