Document No.

GENERAL WORK PERMIT Date of Issue

Pg 1 of 1

Project Title : KMA-SUZUE Logistics Center Overtime Endosed by Required PPE

Extension Project Time SIT Helmet Safety Harness
Date Time (to)
Client : (From) PIC HSE Hi-Vest Ear-Plug
Main Contractor : Safety Gloves Dust Musk
Contractor : Safety Shoes Face Shield
Date : Goggle Proper Attire
Time : to

Discription of Tasks Location Remarks

(✓) tick if applicable / all tools, equipment and PPE must be inspected before use
Usage of Tools & Equipment Hazard Identification
Scaffold Generator Excavator Mobile Crane Distribution Board Electrical Chemical
Ladder Gas Cutter Vibarator Crawler Electric Wire Mechanical Biological
Boom Lift Welding Compactor Piling Machine Electric Tools Sound Radiation
Scissor Lift Grinder Bender Lifting Gear Pneumatic power tool Pressure Air Pollution
Forklift Drill Electric Pump Vibro Hammer Switch Socket Outlet Temperature
Pallet Jack Gas cuylinder Dump Truck Truck Crane Hand tools Gravity
Excavator Jig saw Concrete AG Concrete Pump Others Motion
Check List
Working at Height Scaffolding Erection / Dismantling Excavation
Yes No N/A Yes No N/A Yes No N/A
Used body harness By competent person Checked underground facilities
Install life line Inspection tag available Proper Access/Egress available
Ladder fixed inspected before use Provided proper barricade/warning sign
Simultaneous OPS Adequate access available Equipment operation at safe distance
Covered Floor Opening No opening available Provided signal man
Check List
Lifting Hot Work Electrical
Yes No N/A Yes No N/A Yes No N/A
Lifting Plan submitted Provided fire extinguisher Inspected before ues (wire/tools)
Checked ground condition Removed flammable liquid/material Wire laying on floor or wet surface
Inspected lifting gear Provided fire watchman Clearance from existing height voltage line
Inspected lifting machine Required Housekeeping Dead man switch available at tools
Road closure Used fire blanket Free of defect/properly insulated
Check List
Confined Space Tie-in / Cable Termination Night Work / Housekeeping
Yes No N/A Yes No N/A Yes No N/A
Applied LOTO Applied LOTO Adequate lighting available
Provided ventilation Display isolation tag (Isolation close/open) Provided full supervision
Provided entry/exist log sheet Discharged potential sources Provided walk way
Provided safe access Test before touch Material storage property
Provided rescue plan Provided Standby man Removed protrude nail from work area

REMARKS :

PA (Performing Authority) Issuing Authority

(Contractor PIC) (SIT CM/PM)

Signature : Signature :

Name : Name :

Designation : Designation :

Company : Company :