Heavy Lifting Permit

A Date of Aplication : 5 NOPEMBER 2021

1. Contractor : PT. OKTAVIARY BINTAN FAMILI
2. Period of Work : 1 (SATU) HARI
3. Manpower : VERY ARGANA SAPUTRA 1 (SATU) ORANG
4. Crane/Equipment : MOBILE CRANE
5. Lifting Gears : SLING, SHACKLE
6. Work Description : ERECTION AND STRINGING PIPE SPOOL USING CRANE 45 T ( INCLUDE LOADING
UNLOADING
7. Time : 09.00 WIB To 12.00 WIB
8. Name of Supervisor in-charge : MR. AHMAD DJUMARI
9. Name of Safety in-charge : MR. EDI WARSONO

B Attachment Remarks

1 Is the rigging procedure available? √ Yes No

2 Are the rigging plan & drawing available? √ Yes No
3 Is the load calculation available? √ Yes No
4 Is the JSA/RA available? √ Yes No
5 Is the equipment checklist available? √ Yes No
6 Are the lifting gears documents available? √ Yes No

C Precautions Remarks

1 Is the PPE as required available? √ Yes No

2 Are the warning / caution signs displayed? √ Yes No
3 Does the road need to be blocked? √ Yes No
4 Are there any obstructions to the lifting operation? Yes √ No
5 Are there any potential of falling object? Yes √ No
6 Has the JSA/RA been briefied to all involved? √ Yes No
7 Has the crane been checked? √ Yes No
8 Are communication devices available? √ Yes No

Operating MPI/NDT Confirmed Acknowledged by Client(if Applicable)

Authority

Lifting QA/QC Inspector Client Rep. Client HSE Rep.

Supervisor
Confirmed By PT OKTAVIARY
BINTAN FAMILI Personnel

MR. LAI MR. DONI MR. AWANG

Engineer HSE Personnel Construction Manager

This is to notify that the lifting activity has been completed at :

MR. CHOKY

Lifting Supervisor HSE in-charge

P3-S04-F11/Rev01/2010