AL DHAFRA PAPER MANUFACTURING COMPANY LLC

Long Duration □
Short Duration □ COLD / GENERAL PERMIT Work Permit No:

Department Section Equipment to be worked on:

A. Validity of Permit Date: Start Time: End Time: Equip. ID Work Location

B. Job Description: Requestor Contact No.:

Name:
Tick in the Appropriate Box No. of Persons working under the scope of this permit
C. Type of Isolation / Arrangements Yes No N/A Details & Precautions Isolation Tag No.
Electrical / Valve
1. Process Isolation - System Fully Depressurized State (Tank / Line)
2. Electrical Isolation Required
3. Instrument Isolation (Power / Pneumatic) Required
4. Radiation Isolation, If any
5. Safe Access / Egress Available
6. Working at Height
7. Competent Supervsior / Chargehand available at site
8. Temporary Lighting Arrangement Required
9. Housekeeping Required
10. Adequate Mechanical Ventilation (i.e Fans, Exhaust)
if
11.required
Traffic Management, If any
12. Others, If any
D. PPE Requirement:
□ Safety Helmets □ Safety Shoe □ Safety Goggles □ Face Shield □ Ear Plug □ Cotton Gloves □ Leather Gloves □ Chemical / PVC Gloves □ Safety Harness
□ Cover all □ Fall Arrest □ Dust Mask □ Half Mask □ Gas Monitor □ Air Line □ Edge Protection (Hand Rail) □ Step Ladder □ Mobile Scaffolding
□ Fixed Scaffolding □ Manlift □ Boom Loader □ Mobile Crane □ Barrications & Signages □ Chemical Suit
□ Others, Please Mention if any, ________________________________________________________________________________________________________________

E. Electrical Isolation: (LOTO System)

Name of Requestor: __________________________ Sign of the Requestor: _______________________ PADLOCK / KEY NO: ____________________
Cable Connection Removed □ Yes □ No
Name of Isolator: _____________________________ Sign of the Isolator: ________________________ ○ Long Duration ○ Permit Duration

F. Instrumentation Isolation:
Name of Requestor: ____________________ Sign of the Requestor: _______________________
Airline Removed □ Yes □ No
Name of Isolator: _____________________ Sign of the Isolator: ________________________ ○ Long Duration ○ Permit Duration

G. Gas Test Reading, if any : ○ Required ○ Not Required Gas Test Result __________________________________________________________________
Name of Gas Tester: ………………………………………………………………………………………… Signature of Gas Tester: …………………………………………………………………………………………
I. If the Job is carried out by Contractor, Name of Contracting Company ……………………………………………………………………………………………….... Contact Person: ……………………………………………………………….
J. Permission granted for work to commence
Job preparations & precautions were well explained in TBT / SOP / JSA, etc., to the System is FULLY SAFE to start the Job: I understand the Job explanation, preparation,
Receiver & their Team Permit Issuer (Process Owner): precautions to be taken while executing & will inform
Permit Requestor : Name: …………………………………………………………... the issuing authority about any discrepancies.
Name: ……………………………………………………………………………………... Signature: .………………………………………………………… Permit Receiver Name: …………………………………...
Signature: ………………………………………………………………………………… Date & Time: ...…………………………………………………… Signature: …………………………………………………………
Date & Time: …………………………………………………………………………... Date & Time:………………………………………………………

Safety Officer Name: Date & Time: Remarks:

K. Confirmation from HSE
at the time of Permit Signature:
Issue:

L. Permission / Communication for the TRIAL RUN

Job preparations & precautions were well explained in TBT, SOP & JSA, etc., to the System is FULLY SAFE for the Trial Run: I understand the Job explanation, preparation,
Receiver & their Team Permit Issuer (Process Owner): precautions to be taken while executing & will inform
Permit Requestor Name: ………………………………………………………………………... Name: ……………………………………………………………... the issuing authority about any discrepancies.
Signature: ………………………………………………………………………………………………... Signature: ………………………………………………………… Permit Receiver Name: ..……………………………………...
Date & Time: ……………………………………………………………………………................ Date & Time: …………………………………………………… Signature: .....…………………………………………………………
Date & Time: ...………………………………………………………

J. Extension of Permit, if required Reliever Mobile No.

Date Permit Extend From: Permit Extended upto:
Requestor Name: Permit Issuer (Process Owner): Name Permit Receiver Name
Requestor Sign: Permit Issuer (Process Owner): Sign Permit Receiver Sign
K. Surrender of the Work Permit
• Man, Materials, Tools & Tackles cleared from the work area, Requestor Name Signature Date & Time
• All guards placed back in position.
• Manhole dummies fixed, ensuring that no person/material inside.
• House Keeping to be done from mechanical side.
• The work permit can be closed/ cancelled.
L. Restoration (Process / Issuer)
• All required dummies removed Issuer Name Signature Date & Time
• Necessary valves opened and Isolation tags removed
• System of equipment is ready to start
• Please restore power supply

M. Electrical Authorized Person Name Signature Date & Time

• Motor Cables are connected back
•Power, Control Fuses put back.
• Interlocks connected back & tested The Above Equipment is taken into the Circuit Safely
• Padlock Key returned by Requestor & LOTO Tag removed. Issuer Name Signature Date & Time
• Power restored & Equipment is ready for starting

White Copy: Receiver, Pink Copy: Electrical, Yellow: Permit Issuer / Process Blue Copy: Permit Book
Note: Short Duration valid for 12 hours only Emergency Contact No. 1) Safety Dept. : 056 417 6699 / 02305 2521 2) First Aider : 054 785 5786 / 02305 2536