Hot work Permit Statement

the undersigned below :

NAME : ……………………………………………….

POSITION : ……………………………………………. MV / MT / TB……………………….

GT / FLAG : ………………………………………….

AGENCY : ………………………………………………

Hereby state truthfully that prior to the implementation of hot work activities / repair activities, the
following have been carried out :

1. In the vicinity of the work location, there are no dangerous goods / flammable items.

2. A suitable and sufficient light fire extinguisher has been prepared.

3. There is no loading and unloading activities / passengers.

4. Welding equipment is in good working order.

5. Implementation of activities is directly supervised by the Master / ship crew.

6. The ship / room is already in a free gas state.

7. Signs of activity on the ship have been installed during work.

8. AIS is on and functioning.

9. The vessel is not tendered and is received during the execution of the work.

10. Will not do work at night.

Thus, this statement letter is prepared to be used properly.

Signed bellow : Surabaya , ………………………….

Shipping agency MV/KM/MT/TB ………………….

……………………………….. …………………………………………….