Kind ATTN: Mr. .... : Indoors Yes Outdoors Yes Train No Train

NOIDA METRO RAIL CORPORATION LTD
PERMIT TO WORK / ACCESS TO S&TC EQUIPMENT PAGE - 1 -
Permit No. NMRC/O&M/S&TC Date:
Kind ATTN: Mr. ………………………………………………………....

Part – I ISSUE
Issue to (Name of Person & Agency) ……………………………………………………………………..
PERMIT TO WORK WITH S&TC EQUIPMENT: INDOORS Yes OUTDOORS Yes TRAIN no train
At Station(s) / Train(s)
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
From ……………….. hrs. of Date ……….. to ………… hrs. of Date …………
Signed (authorized representative of Contractor) Date: Time:
Whether above proposed work will interface with existing S&TC equipment in operation: Yes/No
If yes, specify the list of S&TC equipment to remain suspended during the period of Work.
…………………………………………..Track access required.
Note: (1) Functional tests are to be carried out by NMRC/DMRC before clearing the work permit.
(2) Work will be carried out in presence of authorized representative of Contractor.
Whether the existing signalling system is proposed to be altered: Yes/ No

If Yes, specify the following (Attach the separate sheet if require with Permit No. Mentioned on the attachment)
(1) Tests to be performed to certify safety of altered system.

(2) List of document to be supplied before clearing the work permit.
Sign here
Signed (Authorized Representative of Contractor) Date: Time:
Forwarded:
Signed (Authorised Representative of GC/EPIC Date: Time:
Whether above proposed work require Traction Power Shutdown Yes/ No

If yes, specify the section and duration of Traction Power.
From (Location) …………NA…………………………… To (Location) …………………………

………………………………………
From (Location) …………………… of (Date) ………………………to (Time) …………….. of (Date)……………..

Forwarded:
NOIDA METRO RAIL CORPORATION LTD
PERMIT TO WORK / ACCESS TO S&TC EQUIPMENT PAGE - 2 -
Part II RECEIPT
(1) Track / Train Possession Required From / (for Train Set No.) ……………………… To ……………..
(2) Permit To Work Required: S&TC equipment as mentioned in Part I would remain suspended during the
period as mentioned above. Their suspension as above may be confirmed.
(3) Mr. ………………………………………Of NMRC/DMRC will be Engineer’s Possession in Charge (EPIC).
Signed (CFMC / FMC) Date: Time:
Confirmed / Not Confirmed
Signed (Chief Controller) Date: Time:
Approved / Not Approved
I hereby declare that work as mentioned above shall be carried out with the conditions of WORK PERMIT and the
requirements of safety rules of NMRC/DMRC.
Part III (CLEARANCE CERTIFICATE)

(1) I hereby confirm that track is free from obstruction and available for train running.
(2) No alterations have been carried out in the existing S&TC system and the system is safe for train
operation with passengers
(3) Alterations have been carried out in the existing signalling system and the altered S&T equipment is
safe for train operation with passengers. Documents listed in Para (2) of part 1 duly endorsed by GC
are enclosed.

Witnessed: (in cases (2) and (3) above)
(Authorized Representative of GC) (NMRC/DMRC staff on duty) Date: Time
Track is free from obstruction and available from train running. S&TC equipment as mentioned in Part I, suspended
during the period as mentioned above for carrying out modifications and alterations, are hereby reconnected.
Traction Power Shutdown taken as above is also withdrawn. Please Confirm.
Confirmed / Not Confirmed
Signed (Chief Controller) Date: Time:

Kind ATTN: Mr. .... : Indoors Yes Outdoors Yes Train No Train

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NOIDA METRO RAIL CORPORATION LTD

PERMIT TO WORK / ACCESS TO S&TC EQUIPMENT PAGE - 1 -

Permit No. NMRC/O&M/S&TC Date:

Kind ATTN: Mr. ………………………………………………………....

From ……………….. hrs. of Date ……….. to ………… hrs. of Date …………

Signed (authorized representative of Contractor) Date: Time:

…………………………………………..Track access required.

Whether the existing signalling system is proposed to be altered: Yes/ No

(1) Tests to be performed to certify safety of altered system.

Signed (Authorized Representative of Contractor) Date: Time:

Signed (Authorised Representative of GC/EPIC Date: Time:

Whether above proposed work require Traction Power Shutdown Yes/ No

From (Location) …………NA…………………………… To (Location) …………………………

From (Location) …………………… of (Date) ………………………to (Time) …………….. of (Date)……………..

Signed (Authorized Representative of Contractor) Date: Time:

Signed (CFMC / FMC) Date: Time:

Confirmed / Not Confirmed

Signed (Chief Controller) Date: Time:

Approved / Not Approved

Signed (CFMC / FMC) Date: Time:

Signed (Authorized Representative of Contractor) Date: Time:

Part III (CLEARANCE CERTIFICATE)

Signed (Authorized Representative of Contractor) Date: Time:

(Authorized Representative of GC) (NMRC/DMRC staff on duty) Date: Time

Signed (CFMC / FMC) Date: Time:

Confirmed / Not Confirmed

Signed (Chief Controller) Date: Time:

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