电力第一种工作票
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电力第一种工作票
单位______________________________ No. _______________
1. 工作负责人(监护人)________________ 班组______________________
2. 工作班组人员(不包括工作负责人)______________________________________________ _______________________________________________________________________________ ____________________________________________________________________共______人。
3. 工作的线路或设备双重名称(多回路应注明双重称号)______________________________ _______________________________________________________________________________ _______________________________________________________________________________
5. 计划工作时间
自__________年__________月__________日__________时__________分
至__________年__________月__________日__________时__________分
6. 安全措施(必要时可附页绘图说明)
6.1 应改为检修状态的线路间隔名称和应拉开的断路器(开关)、隔离开关(刀闸)、熔断器(保险)(包括分支线、客户线路和配合停电线路)_____________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 6.2 保留或邻近的带电线路、设备__________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 6.3 其他安全措施和注意事项:____________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
工作票签发人签字__________________ __________年______月______日______时______分工作负责人签字__________________ __________年______月______日______时______分
8. 确认工作负责人布置的任务和本施工项目安全措施
工作班组人员签字_______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 9. 工作负责人变动情况
原工作负责人___________________变更____________________为工作负责人
工作票签发人签字__________________ __________年______月______日______时______分10. 工作人员变动情况(增添人员姓名、变动日期及时间)______________________________ _______________________________________________________________________________ _____________________________________________工作负责人签字____________________ 11. 工作票延期
有效期延长到__________年______月______日______时______分
工作负责人签字__________________ __________年______月______日______时______分
工作许可人签字__________________ __________年______月______日______时______分12. 工作票终结
12.1 现场所挂的接地线编号___________________________共______组,已全部拆除、带回。
13. 备注
(1)指定专责监护人____________________负责监护_________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________(地点及具体工作)(2)其他事项___________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________。