Doc.

No : FORM-03-HSE-10
Hot Work Permit Revision : 00
Date : 1 Nov 2017
(HWP) Page : 1 of 1

Project Name/ ID: Contractor: Permit No

In case of emergency the permit will be considered invalid.
A. Time Schedule
Start Date: Finish Date:
From (hh:mm): To (hh:mm):
B. Location Activity

C. Safety Controls (assess together between the permit issuer and the permit holder)
C1. Safety Controls as defined in (all documents MUST be attached to the work permit):
 Job Safety Analysis (Name, doc.no., revision, date):
 Other (Name, doc.no., revision, date):
C2. Additional Safety Controls - Prior commence of work Comments & Definitions
 Energy Isolation (electrical/ mechanical) Energy Control Permit Ref. No.:
 Provide fire extinguisher(s):
 Provide other fire fighting measures:
 Assign fire watch Name:
 Remove combustible and/or flammable materials
 Cover remaining combustable and/or flammable materials/substances/liquids
 Cover floor and wall openings (fire blankets)
 Barricade work area (incl. lower levels)
 Additional measures:
C3. Precautions to be taken: ( Tick marks which are applicable)
Equipment/work area inspected Necessary PPE’s used

Electrical isolation Tag No…………………………………. Equipment Drained/Washed/Isolated

Confined space entry permit No:………………………. Is fire watch personnel is provided?

Earthing properly done/Insulated welding cable
Area barricaded, Caution displayed
used
Are suitable fire extinguishers, in adequate Suitable Tools provided
numbers, kept ready for firefighting? Specify
the type: Gas test has been conducted and safe
Is the area clean and free of combustible/
flammable material
C4. Additional Safety Controls - After work
 Inspection of work area after 30 min. after stopping the work

D. Personal Protective Equipment
[ ] Helmet [ ] Leather Gloves [ ] Ear Plug / Muffs [ ] Face Shield
[ ] Safety Shoes [ ] Safety Glasses [ ] Body Harness [ ] Cotton Gloves
[ ] Rubber Shoes [ ] Safety Goggles [ ] Face Mask Other
E. Work Authorisation (All signatures must be completed or else the permit is invalid)

Contractor/ Permit Requestor: Employer OHSE:

Employer Supervisor: Construction Manager:

F. Nama Pekerja yang Bekerja di Lokasi Kerja Sesuai Ijin Kerja
1 4 7
2 5 8
3 6
9 13 9
G. Confirmation of work completion (Pekerjaan selesai, area dikembalikan ke kondisi awal & aman).
Permit Requestor : Employer OHSE:
Employer Supervisor: Construction Manager:
Date/ Time :