PERMIT TO WORK

The Permit to Work is the ONLY authorized permit to conduct construction activities and to operate equipment on site.
This form shall be issued in conjunction with applicable permit as the means of identifying hazrds and implementing controls
DEPARTMENT OR CONTRACTOR:____________________________________________________________ DATE FILED:______________
SCOPE OF WORK:_________________________________________________________________________ TIME:___________________
_______________________________________________________________________________________ DURATION OF WORK: ______
AREA/BUILDING: _________________________________________________________________________
PERSON IN CHARGE OF WORK:______________________________________________________________ NUMBER OF WORKERS:____
NAME OF PERSONNEL:
1. __________________________________________________ 11. __________________________________________________
2. __________________________________________________ 12. __________________________________________________
3. __________________________________________________ 13. __________________________________________________
4. __________________________________________________ 14. __________________________________________________
5. __________________________________________________ 15. __________________________________________________
6. __________________________________________________ 16. __________________________________________________
7. __________________________________________________ 17. __________________________________________________
8. __________________________________________________ 18. __________________________________________________
9. __________________________________________________ 19. __________________________________________________
10. __________________________________________________ 20. __________________________________________________
EQUIPMENT NO. : __________________________________________________________________________________________________________
EQUIPMENT DESCRIPTION: __________________________________________________________________________________________________
GENERAL WORK CONDITION YES NO N/A

1. If applicable, identify material/product normally found on equipment to be used. ACID BASE

TOXIC ____________________ FLAMMABLE ____________________ HOT ____________________
CORROSIVE _________________________ OTHER ________________________
2. Workplace inspected and was it found free from the above materials?
3. Are workers familiar with applicable SDS?
4. Has the work area and surrounding site been examined to ensure they are free from hazards and will not
create a hazard for this work?
5. Have wind and atmosphere condition been considered to ensure workers safety?
6. Are vehicles allowed in the work area? If yes only to unload necessary tools and equipment required for the job.
7. Are necessarry barriers and warning sign in place?
For confine space entry "NO ENTRY WITHOUT PERMIT"
8. Have overhead and underground hazards been clearly identified?
Underground obstruction : _______________________ Underground and overhead power lines:________________
9. Have electrical swithches been locked out and tagged?
Signature of Electrical Engineer:_______________ Mechanical Engineer:______________
10. Has the necessary equipment been isolated?
Blinding Double Block & Bleed Closed & Locked Valve Plugged Disconnected
12. Special instructions: _____________________________________________________________________________
_________________________________________________________________________________________________
CONTRACTOR ENGINEER / SUPERVISOR / SAFETY OFFICER Checked by: Approved by:
I have read and understand all of the condition of this permit and undertake the responsibility to inform all personnel
working under the authority of this permit of all information contained herein.

__________________________________________________
Name and Signature/ Designation Date:____________________ Safety Officer Project-In-Charge
Closed out:
Accepted Rejected
The work area has been inspected by the Authorized Company Representative after completion of work.
Reason for rejection: __________________
____________________________________
____________________________________________
Signed:______________________Date: ______________________ Time: ______________
____________________________________________
 HOT WORK CONFINED SPACE
Required Pracaution checklist YES NO N/A Required Pracaution checklist YES NO N/A
1. Availability of Fire Extinguisher 1. Personnel trained for Confined Space work
2. Availability of Fire Blanket 2. Personnel trained in Emergency Procedures
3. Adequate illumination 3. Daily Safe Task Instruction (DSTI) done
4. Adequate ventilation 4. Stand by man trained and appointed
5. Signage and barication required 5. Adequate and safe access provided
6. Safe acetylene Gas Cylinder & tubing 6. Safe working platform provided
7. Flash back arrestor installed 7. Adequate illumination provided
8. Pressure guage in good working condition 8. Mechanical air movers / ventilation
9. No flammable / explosive atmosphere 9. Sufficient drinking water available
10. No flammable substance near hot work 10. Confined space temperature acceptable
11. Safe condition of welding equipment 11. Accumulation of hazardous gas
12. Suitable and safe means of access/egress 12. Gas testing (specify below)
13. Good housekeeping in the area ___________________________________________________________
14. Equipment used intrinsically safe ___________________________________________________________
15. Welders certificate of trainings available ___________________________________________________________
16. Daily Safe Task Instruction (DSTI) done ___________________________________________________________
PPE REQUIREMENTS
PPE TYPE Y/N PPE TYPE Y/N PPE TYPE Y/N
Hard Hat High visibility Vest
Self Contained Breathing Apparatus
Goggles Safety Harness
Hearing Protection Life line Gloves
Coverall Safety Shoes / Boots Others:

PROJCT SITE RULES FOR CONTRACTOR

The following rules apply to you and anyone employed by you (including all sub contractors) and it is your responsibility to ensure that they are made aware of these
requirements and comply with them at all times:
1. MOVEMENT ON SITE
Vehicle and pedestrians movements on site must be in accordance with local traffic and restricted to those areas agreed with the company.
2. COMPETENT PERSONS
Persons employed by you shall be competent to undertake the work specified and be able to operate any necessary equipment safely and without risk

3. RISK ASSESSMENT
Any of your activities which pose a significant risk to health and safety of people, property, environment and/or product must be formally assessed, and those likely to
be affected must be informed of the risk and safety measures that are to be taken.
4. TOOLS AND EQUIPMENT
Shall be of good working condition and fit for the intended purpose.
5. PERSONNEL UNIFORM
All contractor must wear their prescribed clean company uniform.
6. HYGIENE
Any applicable hygiene rules must be strictly enforced.
7. FIRE
Notices are displayed throughout the site, you must be aware of site procedures to take if the fire alarm sounded or if you discover a fire.
8. ACCIDENTS
In the event of an accident to yourself or to anyone under your control, it must be reported to your site contact as soon as it is practical to do so.

9. SMOKING
A No Smoking Policy is in place and observance of the policy rules must be strictly obeyed.
10. ALCOHOL and CONTROLLED SUBSTANCES
The consumption of alcohol on site is strictly prohibited, moreover anyone found under the influence of alcohol or other controlled substance will be removed from
site and not be permitted to return.
11. SAFETY OFFICER
Will declare the permit was closed. The area has been inspected and is free from risk and all fire protection system have been reinstated ti their normal operating
status.

THE PERMIT RECEIVER ACKNOWLEDGES THAT HE SHALL INFORM ALL PERSONNEL WORKING UNDER THE AUTHORITY OF THIS PERMIT OF ALL
INFORMATION CONTAINED HEREIN.
Approved Work Permit must be displayed in front of working area

Conforme: Discussed by:

Printed name and signature Printed name and signature

CONTRACTOR SAFETY OF OFFICER