AL DHAFRA PAPER MANUFACTURING COMPANY LLC

Long Duration □
Duration □
Short
HOT WORK PERMIT Work Permit No:

Department Section Equipment to be worked on:

A. Validity of Permit Date: Start Time: End Time: Equip. ID Work Location
Requestor
B. Job Description: Contact No.:
Name:
Tick in the Appropriate Box No. of Persons working under the scope of this permit
Isolation Tag No.
C. Type of Isolation / Arrangements Yes No N/A Details & Precautions Electrical / Valve
1. Job Safety Analysis Available
2. Process Isolation - System Fully Depressurized State (Tank / Line)
3. Electrical Isolation Required
4. Instrument Isolation (Power / Pneumatic) Required
5. Radiation Isolation, Required (If any)
6. Safe Access / Egress Available
7. Working at Height
8. Flammable Materials Removed
9. Competent Supervsior / Chargehand at site
10. Temporary Lighting Arrangement Required / Available
11. Adequate Mechanical Ventilation (i.e Fans, Exhaust)
if
12.required
Housekeeping Required
13. Hot Work Equipments are in good Working Condition
14. Traffic Management, If any
15. Fire Watch / Observer Available

16. 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 □ Fire Extinguisher □ Fire Blancket □ 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: _______________________________________________________________________________

H. Available Fire Watch Name: _____________________________________________________________________________ Contact Number: _______________________________________________________

I. If the Job is carried out by Contractor, Name of Contracting Company ………………………………………………………………………………………………Contact Person: ………………………………………….. Contact Number: …………………………………………………………………..
J. Permission granted for work to commence
Job preparations & precautions were well explained in TBT / SOP / JSA, etc., to the Receiver System is FULLY SAFE to start the Job: I understand the Job explanation, preparation, precautions to be taken while executing & will inform the issuing
& their Team Permit Issuer (Process Owner): authority about any discrepancies.
Permit Requestor : Name: …………………………………………………………... Permit Receiver Name: …………………………………...
Name: ……………………………………………………………………………………... Signature: .………………………………………………………… Signature: …………………………………………………………
Signature: ………………………………………………………………………………… Date & Time: ...…………………………………………………… Date & Time:………………………………………………………
Date & Time: …………………………………………………………………………...

Date & Time: Remarks:

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

L. Permission / Communication for the TRIAL RUN

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

M. 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:
N. 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.

O. 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

P. 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

Q. MONITORING OF JOB SITE (For 1 hour after the Completion of Job)

Responsible Person Name Signature Date & Time

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 : 056 544 8043 / 02305 2536