PY Brennen bunk POARAnEA OVERTIME WORK PERMIT FORM [ENGINEERING PROCUREMENT -CONSTRUCTON NEW/BARU Permit Number / Nomor izin EXTENTION/PERPANJANGAN __| POP/OT/. ied erry _ceseru> 0 [bape] _eowes sire scnandyaiiny/ wana bata Published Date /Tanggal dikeluarkan: Ve .\\. 242 From / Deri | Date Tal (AL 20% [To] teem Location of Work/Lokasi: set ty reece [time Jam: | 9.0 tol 92.00 ‘Work Executor / Pelaksana Pekerjaan : Detail of Job /Uraian Pekerjaan: — gouawe eecr conveyou [DETAILS OF WORKT company Name / Nama Perusahaan Le ee fe / Tanggal 6 a 3005 ffime 7 Jam [ie 0103268 -xacl Job to be executed /Pekerjaan yang - eouine eer convevon jilaksanakan lumber of Workers / Jumiah Pekerja [oe oeane Name of Supervisor / Nama Supervisor [ON Meenyous Phone/Telepon: @e92 389 cen _| B.LIST OF WORKER/ DAFTAR NAMA PEKERJA me NO | Name / Nama No. 1D No Name /Wama Ne.10 T_ [Au averyioas wwe 12 2 tes oe we, 13, a 3 [yee WeLeee 14 4 Wery, wecece 16 : 5 rs were 16 = 6 [vn eannran AEE 7 7 SeINOye Meee 18 ai [ANAC ators Wecere 19 ° 20 70 2 = i ae 2 sen SPECIAL SAFETY INSTRUCTON | INSTRUKS! K3 KHUSUS : THAVE READ, UNDERSTOOD AND CHECKED CONDITION WHERE THE JOB CAN BE DONE | Endorsedby, ‘SAFELY AND AGREE TO OBEY ALL PRECAUTIONS STATED IN THE PERMIT. ‘SAYA SUDAH MEMBACA, MENGERTI, MEMERIKSA KONDIS! DIMANA PEKERJAAN DAPAT DILAKSANAKAN DENGAN AMAN DAN SETUJU UNTUK MEMATUHI SEMUA KETENTUAN YANG | ‘TERTULIS DI IJIN INI ‘Supervisor POP Name ‘uconracior Representa HSE FOP Giant Representative JOB FINISH OR EXTEND 7 PEKERJAAN SELESAl ATAU DITUNDA———————- Pail [I Accept the work (Completed / Extend)", Work Place Has been | 1 time suem | clean and safe Yee /eteraan | Oste/Tenggs!) Tire” | Seva menerima pekerjaan (selesai / ditunda/diperpanjang)*, Tempat kerja telah kemball aman dan bersin, Finish /Seleea: | | Exiond/ Dtundsl ogre Sager oor nee Sore ity Sure Nae Name Name: Mane: | Sore Sarre Serer ereeeene ere oe Sutcontactor ‘superterdent) | cent eprsenaive | superisoreo | __ HS Poe cu apresenate