AL AIN MALL-PERMIT TO WORK Ref: AAM/ EHSMS/ Form-12,

APPLICATION Rev-3
Permit No (For Office Use only):
GENERAL INSTRUCTIONS This permit will be automatically
A work permit is required for any work taking place in Al Ain Mall Premises. Work permit application and the actual works
cancelled in the event of any
shall be strictly complied with Al Ain Mall and ADEHSMS requirements. This permit will be cancelled and the individuals/
emergency evacuation and the work
the company may be banned from Al Ain Mall if any non-compliance on above points are noticed. All work permit
shall be stopped immediately.
applications shall be submitted 3 working days before the date of commencement of work.
PART 1 APPLICANT INFORMATION
Applicant Name Email Address ID Number
Company Name Designation Contact Number
Site Responsible Personnel Contact Number
Sub-Contractors' Name:

PART 2 WORK APPLICATION DETAILS

A) NATURE OF WORK TO BE CARRIED OUT (TICK)- minor works or critical works
Note: Minor Works- Do not need to submit method statement and risk assessment / job safety analysis. Scope of work shall not have any effect on
mall Life safety system and DO NOT include work using scaffoldings or working at height above 3m or heavy machinery.
☐Merchandizing ☐Catering ☐Photography/ Videography ☐Light maintenance works
☐Window front changes ☐Stocktake/ inventory ☐In store light event set-up ☐Branding/ Graphics
☐Access for inspection, survey, etc. ☐Minor Repair works ☐Permit Renewal (Expire permit number____________________
☐CCTV/ AC minor maintenance ☐Others: *Attach previous approved permit.
Note: Critical Works- Scope has significant health and safety concerns and may have impact on mall operation. All documents in E section shall be
submitted. *For Opening/ closing of firefighting valve, Hot works, Confined space entry, Electrical/ Mechanical/ Fire detection isolation, Excavation/
trenching works and any other works identified by ADEHSMS required separate permit to work, shall obtain separate specialist work permit.
☐ Fit-out/ Renovation works ☐ Event/ Kiosk set-up ☐ Impact on services: Fire Alarm& Detection ☐ Yes ☐ No
☐ Heavy maintenance works ☐ Pest control ☐ Working at height >3meter Firefighting system ☐ Yes ☐ No
☐ Emergency ☐ Other: Gas Distribution system ☐ Yes ☐ No
Detailed Description of nature& Scope of work (*Required):

B) DURATION AND LOCATION OF WORK

Date: From ______________ to _______________ ☐ 24 Hours Location/ Unit Name& No:
Time: From ______________ to _______________ ☐ Out of Mall Operational Hours
C) PERSONAL PROTECTIVE EQUIPMENT (PPE) AND OTHER SAFETY EQUIPMENT PROVIDED (TICK)
☐ Fire Extinguishers ☐ Safety Helmets and safety shoes ☐ Safety Vest ☐ Safety Harness
☐ Ear Plugs/ Masks/ Gloves ☐ Warning signs/ safety barriers ☐ Others (Specify): _________________________________
D) EQUIPMENT REQUIRED (TICK)
☐ Man lifts, Boom lifts etc. (MEWP) ☐ Scaffolding ☐ Mobile Crane ☐ Forklifts ☐ Others: __________________
E) DOCUMENT REQUIRED
☐ Machinery/ Operator certificates ☐ Method statement& Risk assessment/ JSA ☐ Copy of Trade license, insurance/Valid ID
☐ Drawings, layout plans, Hoarding ☐ Work Schedule ☐ Others (Specify): ___________________________
PART 3 UNDERTAKING AND AFFIRMATION
1. I confirm that all required safety precautions are in place and fully responsible for the implementation.
2. I confirm that all provided information is reviewed before submitting to Al Ain Mall management and all info are true.
3. I confirm that understood all terms and conditions of the permit application.
Name: __________________________________________ Signature: __________________________ Date: _____________________

PART 4 FOR MALL APPROVAL

Responsible Department: Name: Date: Signature:
Technical Department: Name: Date: Signature:
Health& Safety: Name: Date: Signature:
Security Responsible Person Name: Date: Signature:
Mall FM Service Provider Name: Date: Signature:
PART 5 PERMIT CLOSE OUT
Responsible Department: Name Signature: Date: Time:
Contractor/ Applicant Name: Signature: Date: Time:
*DISCLAIMER:
The applicant and his/her service provider are fully responsible for ensuring the operation is carried out safely by competent persons and workplace is safe for
anyone may be affected by the operation. Granting a permit by Al Ain Mall shall not be construed as AL Ain Mall Management being responsible in anyway, for any
accident that may arise directly or indirectly from your work activities.
Mall Security Emergency Number: 037514001