GI 150 KV TOPOYO (NEW)

OVERTIME PERMIT
Permit No. ABB/MBU-OT/XI/2019/….. HSE Submitted on (Date)
Company Requester Supervisor Valid from (time) AM / PM
Permit Holder/Req. No. of Manpower Valid To (time) AM / PM
Work Area Work Location Type of Work CW / HW / WAH / CS / Elect
DESCRIPTION OF WORK

HAZARDS IDENTIFIED Yes No NA ADDITIONAL CERTIFICATE Yes No NA EMERGENCY CONTACT

Hazardous Gas / Compressed Air* Scaffolder license SM ABB : Hendy Pratomo
Underground Services Operator license Mobile phone : : 081357129088
Flammable / Corrosive Materials* Hot Work Certificate
Electricity / Fire Excavation Certificate HSE ABB :
Moving Particles Lifting Certificate Mobile phone :
Lifting Operations / Manual Handling Working at Hight Certificate
Weather Condition PPE REQUIREMENTS Yes No NA Subcontractor
Noise Safety Helmet Team Lead :
Dust / Fume Safety Goggles Mobile phone :
Adjacent Work Coverall / Work Clothes
Working at Height Hand Gloves HSE :
Confined Space Safety Shoes Mobile phone :
Face Shield
PRECAUTIONS REQUIRED Yes No NA Masker
Lock Out Tag Out (LOTO) Ear Plug / Muff*
Barriers and Signs Full Body Safety Harness
Fire Extinguishers Highlite Vest
Tools and Equipment
First Aid Box / Medic
Lighting (Night Work) ADDITIONAL PRECAUTIONS & SPECIAL CONDITION* (*if any)
Converting Area / Protection - If rain, Stop working
Access and Egress - Do not Start a Work before PTW Approved
Secondary Containment - Use Of PPE ABB Standard Requairement
Spill Kit - Record for a new hazard if any founded
Pre Job / Toolbox Meeting - Gathering immediately a muster point if any emergency situation
- Always make a communication and coordination with authorized person
- Ligthing at the access and Location of work must be appropriate

MANPOWER LIST
1 8 15. 22. 29.
2 9 16. 23. 30.
3 10 17. 24. 31.
4 11 18. 25. 32.
5 12 19. 26. 33.
6 13 20. 27. 34.
7 14 21. 28. 35.
I HAVE READ, UNDERSTOOD AND CHECKED CONDITIONS WHERE THE JOB CAN BE DONE SAFELY AND AGREE TO OBEY ALL PRECAUTIONS STATED
IN THE PERMIT.
SAYA SUDAH MEMBACA, MENGERTI, MEMERIKSA KONDISI DIMANA PEKERJAAN DAPAT DILAKSANAKAN DENGAN AMAN DAN SETUJU UNTUK
MEMATUHI SEMUA KETENTUAN YANG TERTULIS DI IJIN INI

Signature

Permit Issue SM SUBCONT HSE SUBCONT HSE ABB SM ABB

Date & Time :
COMPLETION (by Permit Approver)
JOB COMPLETED JOB NOT COMPLETED

Job/Machinery/Equipment/Area Made Safely Job/Machinery/Equipment/Area Made Safely

Name Name

Signature Signature

Company Company
Date and Time Date and Time