Seri Libana PPC JV Sdn Bhd Doc Ref : SLPPCJV / 140 / PQHSEP / F028

Revision 1 Effective 19.09.2019 Page 1 of 1

Permit To Work
(Hot Work / Confined Space / Working At Height / Excavation / Other Dangerous Activities)

Name of Sub-Contractor: …………………………………………………………………………….…………….…….

Name of Sub-Contractor’s Supervisor: ………………………………………………………………………...……….

Type of Work: …………………………………………………………………………………………...…………….

Location of Work: …………………………………………………………………………………………...…………….

Validity of Permit from: …………………………….……………. to ………………………………………….………..

(Date / Time) (Date / Time)

Please tick if Acknowledge By

Yes (Safety & Health Officer / Supervisor)

1. Have the subcontractor and his employees

been briefed on Site Safety rules? …………………………………………………

2. Have the Subcontractor's tools and equipment

been inspected? …………………………………………………

3. Have the Subcontractor's personal protective

equipment been checked? …………………………………………………

4. Is the HIRADC available? …………………………………………………

This permit is issued by:

……………………………………… ……………………………………… ………………………..………………

(Signature) (Name) (Date / Time)

This permit is received on behalf of the Subcontractor by:

……………………………………… ……………………………………… …………………………..……………

(Signature) (Name) (Date / Time)

Permit To Work closed by:

……………………………………… ……………………………………… ………………..………………………

(Signature) (Name) (Date / Time)

(QHSEMS Version 00) Construction Manual