P R IM A R Y

STRUCTURES
C O R P O R A T IO N

WORK PERMIT

I. PROJECT NAME :_______________________________________________

________________________________________________
Location/Floor Level :____________________
Effectivity Date :____________________
Allowed Working Time :____________________

II. SCOPE OF WORK ________________________________________________

________________________________________________
________________________________________________
________________________________________________

III. REQUESTED BY ( SPECIAL TRADE GROUP/PSC WORKERS)

Contractor’s Name :____________________

Address :____________________
Tel. No. :____________________
Responsible Personnel :____________________
Signature :____________________
Designation :____________________
Contact No. :____________________

IV. WORKERS LIST

Name ID No. Company Name

1. ________________________ ___________ ___________________

2. ________________________ ___________ ___________________
3. ________________________ ___________ ___________________
4. ________________________ ___________ ___________________
5. ________________________ ___________ ___________________
6. ________________________ ___________ ___________________
7. ________________________ ___________ ___________________
8. ________________________ ___________ ___________________
9. ________________________ ___________ ___________________
10. _______________________ ___________ ___________________

V. APPROVED BY: NOTED BY:

__________________________ _______________________
Avalon – Project Engr./Admin Avalon – Project Manager