Public Works Authority

DRAINAGE AFFAIRS
PROJECT DEPARTMENT
P.O. BOX 22188
TEL. 44950000 & 44950999 FAX. 44317015

DOHA WEST SEWAGE TREATMENT WORKS

EXTENSION N° 5
CIVIL PROJECT C807
PROJECT CODE IA 14/15 C077 G
BUDGET REFERENCE

CONSULTANT

CONTRACTOR

Degrémont and all companies of the Group

operate under the brand SUEZ environnement
SUB CONTRACTOR CIVIL DESIGNER

HEALTH and SAFETY

WORK PERMIT Form
ALL RIGHTS RESERVED FOR ALL COUNTRIES
DGT JOB NUMBER
SIZE DATE DRAWN UP CHECKED APPROVED

A4 26/11/15 Guilhem Joly Guilhem Joly Guillaume Peyrissaguet

B-000874

COMPANY FORMAT TYPE ZONE NUMBER REV. VERSION DOCUMENT STATUS COMMENTS STATUS

JVT W Q S 000 085 B 2 FI

B.2 26/11/15 Clarification of HSE staff signatures Guilhem Joly Guilhem Joly Guillaume
Peyrissaguet
B.1 02/11/15 Modification of Work Permit (JVT-W-QS-000-031) for Guilhem Joly Guilhem Joly Guillaume
work on O&M site Peyrissaguet
B 26/05/15 Addition of responsibility mention Guilhem Joly Guilhem Joly Guillaume
Peyrissaguet
A 14/04/15 First Issue Guilhem Joly Guilhem Joly Guillaume
Peyrissaguet
r.v Date Aim of revision Drawn up by Checked by Approved by
 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874 Doc N#: JVT-W-QS-000-031
Health, Safety & Environment r. B – v. 2 Doc Status: FI
WORK PERMIT Form – on O&M site Page 3 / 4 Date: 26/11/15

1 DOCUMENT PRESENTATION

1.1 PURPOSE

This form is to be used to ensure, through technical and organizational measures, the control of
risks of accidents and occupational illnesses, according to the Work Permit Procedure. This form is
a copy of the JVT-W-QS-000-031 Work Permit Form with addition of O&M signatures and specific
case of Tie-In activities. This document is only for activities conducted on the O&M site to ensure a
proper coordination between DB and O&M staffs. In case of Tie-In, the two contractors (Marubeni
and Suez) shall sign as Permit Issuers.

1.2 SCOPE

This document applies to all activities under the responsibility of Degrémont Marubeni JV Doha
West Extension 5 Project conducted on Doha West O&M site (Extension 2, 3 and 4). The list of
required activities were a Work Permit is mandatory is detailed in the Work Permit Procedure.

1.3 TO BE CARRIED OUT BY:

Title Main role

Permit Issuer Issues the permit
Controls the respect of the permit on site
Analyzes the risks
HSE Officer Inspect compliance on site
Permit Holder Carries out the intervention as per the Work Permit instructions
Permit requester Requests for the work permit
Participate to the risk analysis
Ensure compliance with work permit content

1.4 REFERENCES

JVT-W-QS-000-830 Work Permit Procedure

1.5 DEFINITIONS

Work permit Safe work permit is a written record that authorizes an employee
with a specific work, at a specific location, for a specific period of
time
Permit requester Person requesting for a Work Permit
Permit holder Person carrying out the intervention
Permit issuer Person issuing the permit and therefore authorizing the start of
the intervention
2 CONTENT
See next page

The 3 first pages of this document must be removed before using the document.

Approved by: Guillaume Peyrissaguet Checked by: Guilhem Joly Drawn up by: Guilhem Joly
Degrémont Marubeni JV Copyright - No reproduction without permission
 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874 Doc N#: JVT-W-QS-000-031
Health, Safety & Environment r. B – v. 2 Doc Status: FI
WORK PERMIT Form – on O&M site Page 4 / 4 Date: 26/11/15
Work Permit N#:
DESCRIPTION OF WORK
Name of contractor: Requester Name: Date of request:
Area: Building : Equipment Tag:
Duration of work: Date and starting hour: Date and ending hour (forecast):
Nature of the work:

Number of intervener worker : Permit Holder Name:

Name and surname of intervener worker : Equipment list:

EQUIPMENT TO BE LOCKED YES NO DB and O&M Tie In YES NO

If YES then refer to attached ISOLATION CERTIFICATE mentioning all references and details. The If YES the Work Permit shall be signed by O&M,
form must be signed by the LOTO responsible and the supervisor before signing the Work Permit. MARUBENI and SUEZ DB
CO-ACTIVITY YES NO
If risk of co-activity with another department or company,
indicate the additional safety measures or attach a document specifying the measures:
IDENTIFICATION OF HAZARDS AND RISKS
Fall from same level Load lifting Burns (chemical / thermal) Pneumatic (tools, energy, ...)
Fall from height Electricity (current and / or static) Underwater works Extreme temperature
Falling objects Biological Fire and sparks Water pollution
Moving parts Noise ATEX (explosion) Air pollution
Crushing Excavation Pressure (steam / hydraulic / tools) Soil pollution
Asphyxia (CO / N2 /…) Circulation (clash by car) Chemical (working with or near products) Other:
Intoxication (H2S / Cl2 / O3 /.) Cable or pipe (buried / overhead) Ionizing radiation
MATERIAL REQUIRED FOR THE WORK
Truck (> 3,5 t)
Hand tools Blowtorch Individual rolling platform Energy:
Lifting device: max load=
Tools (electric / pneumatic) Welding machine Mobile platform (nacelle) Fluid:
Load weight:
Compressor Scaffolding High Pressure Cleaner Other:
Resistance sling / cable:
SPECIAL PERMIT TO APPLY YES NO
Fire Permit / hotspots Excavation permits Entry Permit / confined spaces Work at height
ATEX area Underwater works Lockouts (electric / mechanical / hydraulic) Radiography permit
MEASURES OF PREVENTION AND PROTECTION means ‘‘mandatory’’
Helmet Full face mask with cartridge Coverall for chemicals risks ATEX lighting Forced ventilation
Safety shoes Breathing apparatus Waders Very low voltage lighting Inerting……………
Safety glass Self-rescue apparatus Safety boots Fire extinguisher Life jacket
Coverall Ear protection Chemical boots Continuous water spreading Signage of construction site
High visibility jacket Leather gloves for handling Harness System of alarm/alert Screen / Cover
Goggles UV Gloves for chemical risk Shock absorber Walkie Talkie Equipment for electrical works
Face shield Gloves for biological risk Multi-Gas detector Contact control room Marking of construction site (day/night)
Welder face shield Gloves thermal risk H2S Gas detector Road closure Watchman outside permanently
Dust mask (FFP2) Coverall for dust Tripod / hoist Alone Worker Protection Presence of safety officer
Dust mask (FFP3) Cooling vest Stop fall communication Other:
Thermal coverall Lifeline ATEX materials
MEASURES OF ENVIRONMENTAL MANAGEMENT
Waste Management Management of anomalies (straining, leaks ...)
Waste tipper available on site Location:________________ Presence of absorbent (antipollution kit) Shutter / Leak arrester
Recovery of waste by subcontractors Presence of retention tank Other:
Other: Straining bins
CERTIFICATE / DOCUMENT REQUIRED FOR THIS PERMIT (must be attached to the work permit)
Special permit (see top) Material safety data sheet Job Risk Analysis Other:
Intervention Procedure / modus operandi Document of equipment control (to specify) Accreditation / authorization interveners
Comments:

VALIDATION OF WORK PERMIT

Permit Requester Permit Holder Permit Issuer JV HSE Manager HSE Officer
Date:
Name:
Date
Name:
Date:
Name: DB OM Date:
Name: DB OM
Company: Company: Company: Company:
Signature: Signature: Signature: Signature:
I ensured that the safety I will use the safety precautions I understand these work hazards and ensured I have checked the above conditions and
precautions are sufficient. listed in this document. that operatives know them consider it safe for this work.
WORK PERMIT RENEWAL * it is recalled that Vigiminute (pre-job control intervention) must be observed before starting work
Permit Issuer HSE
Date Start time Finish time Permit Holder
DB PM O&M HoD DB HSE Off. O&M HSE Off.
st
1 day
2nd day
3rd day
4th day
5th day
6th day
Friday Works on Friday are not authorized in this form (use the special work permit form for works on Friday)
END OF WORK
Permit Holder Permit Issuer
Finished work? YES NO Finished work? YES NO
All the persons under my orders left the working zone. Places are tidied up, cleaned and the Work is accepted and I personally checked the status of the work area
waste evacuated. The collective protections are put back in place. Name: Company:
Name: Company: Signature: Date: Hour:
Date: Hour: Signature :
White copy: Permit Issuer Green: HSE Office Yellow: Permit Requester Pink: Permit Holder

Approved by: Guillaume Peyrissaguet Checked by: Guilhem Joly Drawn up by: Guilhem Joly
Degrémont Marubeni JV Copyright - No reproduction without permission