SAFE WORK PERMIT (SWP)

Facility: ______________________________________ Emergency Number: +62081295670089__

SECTION I – GENERAL SWP SWP Max Duration = 24 hours or 2 shifts, whichever is shorter
1. What is the scope and location of permitted work? (Work limited to Scope, Location, Description, Tasks, Area/Equipment, Tools and Boundaries described)
A. Intervesi electrical, B. installation piping AHU C. welding piping AHU D. installation AHU E. intallation ducting ___
Tools : Hand Tools, Cup Suction Holder, Manual Cutting Tools, grinding machine, scaffolding, ladder, senai machine, welding machine ___
Location at WTC Building 3 ___
___
Does the scope of work include the following? If yes, complete the additional Sections of the SWP
Isolation of Energy Sources (Section II) Yes N/A Heavy Equipment (Section XII) Yes N/A
Confined Space Entry (Section IX) Yes N/A Hot Work (Section VI) Yes N/A
Electrical Work (Section X) Yes N/A Hydroblasting (Section XIII) Yes N/A
Excavation (Section XI) Yes N/A Pressure Washing (Section XIII) Yes N/A
Fall Prevention (Section VIII) Yes N/A Line & Equipment Opening (Section VII) Yes N/A
Critical Lift Yes N/A Small Unmanned Aerial System (Section XIV) Yes N/A
Additional SWP Issuer Comments, Information or Instructions: Danger Of installation work ( Dust, fall accidentally, electric shock, emergency preperanes)

2. Have all people working under this SWP received the necessary facility and/or site orientation? Yes
Emergency procedures, alarms, evacuation routes, assembly points, and location of nearest safety shower(s), eye bath(s), fire
extinguisher(s) and telephone and/or intercom are reviewed with, and understood by, the worker(s)? Yes
Scope and boundaries of any work that could potentially impact the permitted work has been reviewed and is understood? Yes N/A
Other workers in adjacent areas were notified if this permitted work could impact their work/area? Yes N/A
All equipment to be worked on is properly prepared, identified and is ready to work on? Yes N/A
For demolition or renovation work, has the work area been inspected for asbestos? Yes N/A
Portable electrical equipment used has a GFCI/RCD (EWP-10) or follows an approved Assured Grounding Program (EWP-10) Yes N/A
Will the work create holes, unprotected edges or other fall hazards? If triggers for elevated work are met, complete Section VIII Yes N/A
Do workers have specialty training as required? [ ] HAZWOPER [ ] Asbestos [ ] Lead [ ] Silica [ V ] Other: Emergency Yes N/A
3. Additional information, permits and/or checklists used (based on scope and type of work) are attached to the SWP? JSA Yes N/A
4. Field Tests/Monitoring needed (other than that specified in Hot Work VI or CSE Section IX)? (e.g., noise, etc.) Yes No If yes,
describe the Scope of Monitoring:__________________________________________________________________________________________________
Monitoring performed by: ____________________________ Date: _____________ Time_____________
Field Tests and/or Monitoring Results:______________________________________________________________________________________________

5. Chemical Hazards List the chemical hazards of the work area, and/or process chemical(s) last contained in equipment, and any job Doesn’t Apply [ ]
specific chemicals used. See SDS(s) for health & safety hazard(s).
Chemical(s) Name:__ Compound_______________________________ [ ] Flammable [ ] Corrosive [ ] Reactive [ ] Toxic [ ] Carcinogen
[ ] Sensitizer [ ] Asphyxiation [V ] Skin Irritant [ ] Inhalation [ ] Other: ____________________________________________________
If chemical hazards exist, describe safeguard(s) used: Use Face shield, ear plug, heavy duty leathergloves, safety glasses, safety shoes, safety
helmet, long sleeves, Dust mask ___________________________________________________________________

6. Physical Hazards List the hazards of the work, area, equipment and tools used, e.g., Doesn’t Apply [ ]
[ ] Oxygen Deficient Atmosphere [V ] Vibration [ ] Pressure [ V ] Noise (>85dBA) [ ] Radiation [ V ] Sharp Edges
[ ] Electricity/High Voltage [ ] Shock Hazard [ ] Arc Flash [ ] Heights [ V ] Falling Objects [ ] Flying Debris [ V ] Pinch Points
[ ] Congested Area [ ] Heat/Cold Stress [ V ] Burns [ V ] Dust [ ] Line of Fire [ ] Other: ______________________
If physical hazards exist, describe safeguard(s) used: Use Face shield, ear plug, heavy duty leathergloves, Chemical Resistant
Gloves, safety glasses, safety shoes, safety helmet, long sleeves, Dust mask
________________________________________________________________________________

7. Biological Hazards, e.g., [ ] Water or waste contaminated with potentially infectious materials Doesn’t Apply [ V ]
[ ] Insects [ ] Animals [ ] Microorganisms [ ] Harmful/Poisonous Plants [ ] Other: ______________________
If biological hazards exist, describe safeguard(s) used:
8. Environmental Considerations, e.g., [ ] Waste Disposal [V] Housekeeping [ ] Lead Paint Doesn’t Apply [ ]
[ ] Waste generation (solid waste / wastewater) [ ] Management of generated waste [ ] Impact to air, ground or water [ ] Other:____________
If environmental considerations exist, describe safeguard(s) used: Provide construction junk area and Construction junk shall be evacuated out from
Metropolitan complex daily
9. Ergonomic Considerations, e.g., [ V ] Bending [ V ] Lifting [ ] Awkward Posture/Position Doesn’t Apply [ ]
[ ] Pushing/Pulling [ ] Forceful Exertion [ V ] Repetitive Motion [ ] Heavy Object(s) [ V ] Manual Handling [ V ] Inadequate Lighting
[ ] Other: If ergonomic considerations exist, describe safeguard(s) used: use Back Corset, trolley, safety talk about material handling,
provide standing lights
10. Personal Protective Equipment (PPE) PPE below is not inclusive of all PPE available. Refer to Facility / Business PPE Grids and SDSs as needed
Face/Head Respiratory Protection Hands Body Feet/Legs
[ V ] Face Shield, Type: [ ] Air Pack (SCBA) [ ] Chemical Resistant [ ] Apron [ ] Composite Toe Shoes
_________________ [ V ] Dust Mask Gloves [ ] Chemical Resistant Suit [ ] Dielectric Boots
[ ] Hood, Type: [ ] Escape Respirator [ V ] Cotton Gloves [ ] Cooling PPE:___________ [ ] Knee Pads
_________________ [ ] Full Face Cartridge [ V ] Cut Resistant [ ] Fire Resistant Clothing [ ] Metatarsal Boots rated for
[ ] Welding Hood [ ] Half Face Cartridge Gloves [ ] High Visibility Clothing/Vest pressure being used
[ V ] Other: Cartridge Type: [ V ] Leather Gloves [ ] Personal Flotation Device [ ] Protective Leggings
Helm___________ __________ [V ] Rubber Gloves [ ] Tyvek Suit [ ] Rubber Boots
________________ [ ] Full Face Air Supply [ ] Welding Gloves [ V ] Other: Long sleeve T-shirt & [ V ] Steel Toe Shoes
[ ] Other: [ ] Other: Vest [ ] Other:
Eyes Ears Arms Electrical
[ ] Chemical Goggles Hearing Protection: [ V ] Long Sleeves [ ] Rubber Insulating Blanket/Matting [ ] Rubber Insulating Cover(s)
[ ] Cutting Goggles [ ] Single [ ] Double [ ] Protective Sleeves, [ ] Arc Flash PPE (EWP-21) [ ] Voltage-rated Tools (EWP-32)
[ V ] Safety Glasses with [ ] Limit time exposure: Cut Resistant [V ] Electrical Rubber Insulating Gloves (EWP-22)
Side Shields ____________________ [ ] Protective Sleeves,
[ ] FRP Live-line Tools (EWP-32) [ ] Temporary Protective Grounds
[ ] Other: ___________ [ V ] Other:<85 Dba : ear Leather
plug [ V ] Other: Non electrical contact_______________________
[ ] Other:

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 SAFE WORK PERMIT (SWP)
Facility: ______________________________________ Emergency Number: +62081295670089__
Specify if, or when, the PPE to be used is task specific, e.g., “face shield and ear plugs needed only when cutting”: Use the basic PPE when start any
construction steps, Face shield, ear plug, heavy duty leathergloves,rubber gloves, safety glasses, safety shoes, safety helmet, long sleeves, Dust
mask needed only when cutting

11. Barricades needed? Yes No If yes, describe method and barricade distance(s): ___________________________________________________

Warning Signs: [ V ] Caution [ ] Danger [ ] Hydroblast [ ] Splash Guards [ ] Nitrogen Purge [ ] X-Ray [ ] Respiratory [ ] Hearing
[ ] Abrasive Blast [ ] Traffic control (e.g., Fork Lift Trucks, Heavy Equipment) [ ] Other:

SECTION II Isolation of Energy Sources (IOES) Doesn’t Apply [ V ]

1. Master Red Tag System Used? Yes No 1. Individual Red Tag System Used? Yes No
Red Tag Master (RTM) #(s):___________________________ Scope of Isolation:_____________________________________
2. Have Isolator and Independent Reviewer documented their Yes 2. Isolator and Independent Reviewer documented their verification
verification of the isolation? of the isolation? Yes
3. Scope of isolation reviewed with SWP Receiver? Yes 3. Scope of isolation reviewed with SWP Receiver? Yes
4. Workers accepted the Red Tag Master? Yes 4. Workers attached their Individual Red Tag(s)? Yes
5. SWP Receiver reviewed scope of isolation with crew members? Yes 5. Workers completed their Individual Location Listing? Yes
6. SWP Receiver signed the Red Tag Master? Yes 6. SWP Receiver communicated scope of isolation to their workers? Yes
7. Did any workers use Individual Red Tags? Yes No If yes,
Are worker’s Individual Red Tag(s) attached? Yes
Did workers complete their Individual Location Listing? Yes
1. Energy Control Operating Procedure (ECOP) Used? Yes No If yes, procedure name:

SECTION III Safe Work Permit Activation

As the SWP Receiver my signature indicates I: As the SWP Issuer my signature indicates I:
1. Listed all workers working under this SWP Yes N/A 1. Reviewed this SWP with the SWP Receiver Yes
2. Reviewed the contents of this SWP with my workers Yes N/A 2. Completed the initial on-site inspection with SWP Receiver Yes
3. Confirm I/workers understand the: 3. Determined that on-site inspections ARE ARE NOT
a) Scope and requirements of this SWP including emergency needed during the permitted work. If needed, describe scope
procedures, alarms and assembly points Yes of inspection:_______________________________________________
b) Need to notify SWP Issuer if job scope or work conditions __________________________________________________________
change Yes 4. Determined that on-site close out inspection beyond those listed in
4. Confirm I/workers have necessary skills/knowledge to do the SWP Close Out Section V IS IS NOT needed. If needed,
permitted work safely and properly use PPE Yes describe scope of inspection: __________________________________
5. Non U.S. ONLY: Communicated the original isolation and any __________________________________________________________
changes to it with my workers, and I will accept/release RTM and 5. Notified joint equipment owners. Yes N/A
Isolation Forms on behalf of all workers listed below, or on the If yes, Signature of joint equipment owner: ______________________
attached SWP Crew Roster. Yes 6. Notified adjacent facilities if work could impact them. Yes N/A
Names (print) of all workers covered by this SWP: ___________________ If yes, Signature of adjacent area owner(s):______________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________or SWP Crew Roster Attached Yes N/A
SWP Receiver Name: ___FARIS SAGITA____________________________ SWP Issuer Name: _____JHON LUTHER P__________________________
SWP Receiver Signature: _______________________________________ SWP Issuer Signature: __________________________________________
Date: Time: 08:00 S/D 04:00 Date: 1 Agustus 2019_____ Start Time: ___08:00__ End Time: _24:00____
SWP Receiver Company: ___PT OMEGA MOVERINDO SUKSES____________________________________
SWP Reassigned to: SWP Receiver Name/Signature:_BUSRO JUNAIDI_________/__________________________
Date: 1 Agustus 2019 Time: 08:00

SECTION IV Safe Work Permit Change(s) Doesn’t Apply [ V ]

1. Reason for SWP Change(s): 2. Is a new SWP needed? Yes No If no,
Past SWP End Time Change in Work Scope Is information on SWP still accurate? Yes No If no,
Change in Work Condition(s) Work Stoppage, e.g., evacuation Is an on-site inspection needed? Yes No
Complete Change in Work Crew Has SWP Issuer documented and initialed all changes on SWP? Yes
Other: Has SWP Issuer reviewed all changes with SWP Receiver? Yes

SECTION V Safe Work Permit Close Out

As the SWP Receiver my signature indicates: As the SWP Issuer my signature indicates I:
1. I informed the SWP Issuer of the status of the permitted work Yes 1. Reviewed the status of the permitted work, equipment and
2. Work described in the SWP is completed Yes No the work area with the SWP Receiver Yes
If no, describe the status: ______________________________________ 2. Completed the on-site close out inspection for work that:
__________________________________________________________ Involved removal/impairment of a safeguard critical to life Yes N/A
3. I/all my workers covered by this SWP have stopped working Yes Created a hazard that required a safeguard critical to life Yes N/A
4. I acknowledge this SWP is no longer active Yes Involved erection, modification or removal of LCG’s Yes N/A
Is described in Section III Line 4 Yes N/A
3. Confirmed LCG were replaced with permanent guardrails,
flooring, grating or work area was returned to original state Yes N/A
4. Confirmed grating was inspected by a Qualified Grating Inspector if it
was reinstalled after being disturbed, removed or damaged Yes N/A
5. Notified Rope Access Rescue Team that work is complete Yes N/A

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 SAFE WORK PERMIT (SWP)
Facility: ______________________________________ Emergency Number: +62081295670089__
SWP Receiver Name: ___Faris Sagita _______________________________ SWP Issuer Name: _______JHON LUTHER P________________________
SWP Receiver Signature: _______________________________________ SWP Issuer Signature: ___________________________________________
Date: 1 Agustus 2019 Time: 19:00 Date: : 1 Agustus 2019 Time: 19:00

SECTION VI Hot Work Doesn’t Apply [V]

1. Location of Hot Work: WTC 3 Building 11. Are there other materials that can generate pressure increase or
_________________________________________ hazardous vapors upon heating? Yes No If yes, describe
2. Hot Work Area Classification: Flammable General Exempt precautions to eliminate / minimize hazards: ______________________
3. Type of Hot Work: Low Energy (complete questions 1-9) _________________________________________________________
High Energy (complete questions 1-17) ________________________________________________________
4. Line/Equipment status: In Service Drained Cleared 12. Is equipment corrosion present that can generate flammable
Cleaned Depressurized New Other:______________ materials? Yes No If yes, choose at least one of
N/A the following:
5. Line/equipment isolated with: Air Gap with Misalignment Blinds Corrosion has been removed where Hot Work will occur
Double Block & Bleed - if used, Name of Secondary Approver: Ventilate line/equipment
______________________________________________
Other: ______________________________________________
Alternative Isolation - if used, FWGL Approval, Name: ____________
13. Fire Protection needed? Yes N/A
& RCL or Delegate Approval, Name: ___________________________
Fire extinguisher type: CO2 Powder Other: _____________
N/A
Fire extinguisher is full? Yes
6. Is there potential for flammable materials to be trapped behind liners
Combustible/flammables moved at least 35 ft/11m? Yes No N/A
or in dead legs? Yes No If yes, describe
If no, choose one or more of the following as guard or shield:
method(s) to clear equipment: ________________________________
Spark Protection Water Spray Wetted Tarps
_________________________________________________________
Other: _________________________________________________
7. Purging needed? Yes N/A If yes,
Chemical sewer drains within 35 ft /11 m covered? Yes N/A
Indicate purge gas: ________________________________________
Fire protection system disabled? Yes N/A
Describe how done: _______________________________________
If yes, describe alternative fire protection:_________________________
Describe ventilation needs:_________________________________
__________________________________________________________
8. Flammable atmosphere monitoring required? Yes N/A
14. Connections & hoses checked for leaks if flammable materials
If yes, location of monitoring: _________________________________
are introduced, e.g., acetylene, cylinders? Yes N/A
Monitoring frequency: Initial Only Continuous Periodic
15. Heat exposure to gaskets, seals, liners can occur? Yes No
If periodic, describe frequency: _______________________________
If yes, describe precautions: __________________________________
Monitoring date: ___________________ Time: __________________
_________________________________________________________
Name of person who did monitoring:___________________________
16. Safety Attendant Name (for High Energy Hot Work): N/A
Meters bump tested or calibrated prior to days use? Yes
_________________________________________________________
Level of flammables detected: 0% LEL Other, describe: _____
17. Name of Secondary Approver that approved High Energy Hot N/A
_________________________________________________________
in a Flammable Area:_____________________________________
9. Nearby activities which can generate flammable atmospheres
prohibited until Hot Work is complete? Yes N/A
10. List flammable and/or combustible materials within the work
area: ____________________________________ AND last contained
in the equipment: ___________________________________________

SECTION VIII Fall Prevention

1. Method(s) workers will use to access elevated work area: 6. Pre-use check complete for: Aerial Lift: Yes N/A
Aerial Lift Scissor Lift Crane Suspended Work Platform: Yes N/A
Ladder If used, is ladder 6 ft/1.8 m or more from a guardrail Suspended Work Platform: Yes N/A
or unprotected edge? Yes No If no, 7. Methods used to store and prevent objects and equipment from falling: N/A
choose one: Fall Arrest or Extend Guardrail(s) Tool Tether/Lanyard Tool Holster Tool Pouch
Mobile Elevated Work Platform Mobile Ladder Stand Wristbands Secured Containers Nets Tool Belt
Rope Access - FWGL Approval, Name: No job Rope Access__ Toe Boards Other: ______________________________________
Scope of SWP aligns with Rope Access Work Plan? Yes 8. Method(s) used to lift equipment: N/A
Work is performed by at least two Certified Rope Access Aerial Lift Crane Hoist
Technicians, one of which is a Level III Technician? Yes Rope Other: ________________________________
Rescue workers notified before work begins? Yes 9. Describe rescue method(s) to be used: N/A
Scaffold – Approved by Competent Scaffold Builder? Yes Aerial Lift Ladder Self-Lowering Device
Scope of SWP aligns with intended use, limitations and Rescue Team Other: _______________________________
precautions marked on the scaffold? Yes 10. Method(s) for workers doing elevated work to communicate with workers
FWGL Approval, Name: _______________________ if erecting, on the ground: Radios Verbal Hand Signal
modifying, dismantling scaffold that is cantilevered, a scaffold Other:_________________________________________________
tent, uses building/structure for support with gap > 1 ft/30 cm, 11. Workers are available on the ground to operate the controls of
or is a scaffold bridge longer than 25 ft/7.5 m elevated work equipment? Yes N/A
Suspended Work Platform - FWGL Approval, Name: ____________ 12. Will Life Critical Guards (LCG) be erected/modified/removed? Yes N/A
Checked by Competent Person? Yes FWGL Approval, Name (if erected or modified):________________________
If suspended from crane, Crane Operator is certified? Yes Safety Attendant(s) used? (max 2 hrs) Yes N/A
Other: Work on surface_______________________________________
2. Fall Prevention to be used: Guardrail(s) Cover(s) Work on Roof(s) Doesn’t Apply [V]
Life Critical Guards (LCGs) with labels 13. Will work occur within 6 ft./1.8 m of the edge of a flat or low
Fall Restraint System Fall Arrest System Safety Net sloped roof? Yes N/A
Other: __________________________________ If yes, choose one or more of the following:
3. Identify Approved Anchor Point(s) to be used: N/A Guardrails Fall Restraint Fall Arrest Safety Net
Structural Steel Approved Piping 14. NON U.S. ONLY: Will work occur between 6 ft / 1.8 m and 15 ft / 4.5 m
Insulated Pipe – FWGL Approval, Name: _____________________ of the edge of a low sloped roof? Yes N/A
Scaffold Components – Competent Scaffold Builder Approval, If yes, choose one or more of the following:
Name: _______________________________________________ Guardrails Fall Restraint Fall Arrest Safety Net
Mobile Anchor Point - Checked by Competent Person prior Warning lines made of rope, wires or chains, and stanchions

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 SAFE WORK PERMIT (SWP)
Facility: ______________________________________ Emergency Number: +62081295670089__
to use? Yes placed at least 6 ft/1.8 m from the roof edge
Vertical Lifeline Horizontal Lifeline 15. U.S. ONLY: Will work occur between 6 ft and 15 ft of the edge of a
Mobile Crane Hook flat or low sloped roof? Yes N/A
Other - Approved by Qualified Person: _______________________ If yes, choose one or more of the following:
4. Will workers/equipment be on surfaces not designed for walking or Guardrails Fall Restraint Fall Arrest Safety Net
working? Yes No If yes, Warning lines made of rope, wires or chains, and stanchions
describe method(s) to address hazards: Distribute Weight placed close to the work area but no less than 6 ft from the roof edge
Barricade Fall Arrest Other (recommended by (if work is infrequent and temporary and is not construction)
Structural Engineer): ____________________________________ 16. U.S. ONLY: Will work occur greater than 15 ft from the edge of a
_____________________________________________________ flat or low sloped roof? Yes N/A
FWGL Approval, Name: __________________________________ If yes, choose one or more of the following:
5. Will equipment be used to lift workers? Yes No If yes, Guardrails Fall Restraint Fall Arrest Safety Net
does equipment have crush protection or is it an electrically insulated Warning lines made of rope, wires or chains, and stanchions
bucket truck with guarded controls & spotter? Yes No If no, placed close to the work area but no less than 6 ft from the roof edge
describe administrative controls used: ______________________ A work rule that restricts access to within 15 ft of roof edge
_________________________________________________ and (if work is infrequent and temporary and is not construction)
FWGL Signature: ______________________________________ 17. Will work occur on a steep sloped roof? Yes N/A
Equipment can be operated from the ground? Yes If yes, choose one or more of the following:
Will equipment lifting workers enter tight or restricted Guardrails Fall Arrest Safety Net
space(s)? Yes No If yes,
FWGL or EHS Delivery Leader or Project Leader Approval, Name:
_____________________________________________________

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