Permit No.

: HDEC-MECH-2019-001
GENERAL PERMIT Date: 28 March 2019
Contractor Name: HDEC
Permit Work Activity; Installation Warehouse Method Statement: Required ☐ Yes ☐ No
SECTION 1 WORK REQUEST
PTW Issuing Authority: Ilmansyah Badge No.:
Contact No. 081374666085 Work Location: Near Office DSS
SECTION 2 ACTIVITY SPECIFIC DETAILS
Activity Hazards Control Measures
SEE JSA
SECTION 3 PROTECTIVE EQUIPMENT
☐ Clothing ☐ Ear Plug / Ear Muff ☐ Full Body Harness ☐ PersonalH2S Detector
☐ Safety Helmet ☐ Dust / Gas Mask ☐ Lifeline ☐ Others ( Specify)
☐ Safety Shoes ☐ Gloves ( ___________ ) ☐ Fire Extinguisher
☐ Eye Protection ☐ Face Shield ☐ Respirator /SCBA
SECTION 4 ADDITIONAL PERMIT REQUIRED
☐ Not Applicable ☐ Confined Space Entry ☐ Excavation ☐ Hot Work
☐ Non-Critical Lift ☐ Critical Lifting ☐ Non-Destructive Testing ☐ Others (Specify)
SECTION 5 APPROVAL
HDEC Construction team Signature: Date:
HDEC Safety Team Signature: Date:
Permit Start Date: 29 March 2019 Permit Finish Date: 04 April 2019
Section 6 PERMIT EXTENSION APPROVALS
PTW Issuing Authority Signature: Valid Until:

Department Architecture/ Civil Piping/ HVAC Mechanical Electrical Instrument

Name
Signature
Date
Section 8 PTW ACCEPTANCE
PTW Holder (Task Supervisor) Signature: Date:
Contact No. No. of Working Persons on PTW
Section 9 PTW Daily Inspection by HDEC Safety team
Date PTW Inspector Name Signature Date PTW Inspector Name Signature
Mon Fri
Tue Sat
Wed Sun
Thu
Section 10 PTW CLOSED
PTW Issuing Authority Name Badge number Signature Date