@ PT.PANCA DUTA PRAKARSA OVERTIME WORK PERMIT FORM ENGINEERING PROCUREMENT - CONSTRUCTION NEW/BARU Permit Number / Nomor izin EXTENTION, PERPANJANGAN _ | POP/OT/ J ‘Area: Lewy TeEcTe | Dept: TEAM we Validity / Masa beriaku Published Date /Tanggal dikeluarkan: 6. . 2554 From ari] Date Tal: pene | To] zeae Location of Work/Lokasi: JETTY teen Time/Jam: | wee | Tol 21-00 | Work Executor / Pelaksana Pekerjaan : ] ane | Detail of Job/Uraian Pekerjaan: - ne iw era semen CDETAILS OF WORKT “ompany Name /Nama Perusahaan pe ei Date /Tanggal prmeeivaest a a {Time /Jam Herero aes = Exact Job to be executed/ Pekeqjaan yang? - pBlaksanakan NAAN YANG mew eA fener) Number of Workers / Jumiah Pekeyja [re eeane at ame of Supervisor / Nama Supervisor Plane Phone /Telepon : B. LIST OF WORKER / DAFTAR NAMA PEKERJA ‘NO _| Name / Nama No. 1D Name / Nama Wo. 10 1] pepo LAT ae mw ene weer 2 [ya went sor onante eee 3) BANAL REARS | WR = wovae i wea cer 4 | erusmen waven. CE Fonene ever 5_| vb AST Meat. feu Bamoane $ uc 6 | sewaeno Meat Cau Oran Ie wee T | ‘Re = Aer TT vareginc ot a3 Ree 7 SeRTS. Te TL MRE eect serene TIRES 10 | Temwoncy eee I Th Yann eee eee zl 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 KONDISI DIMANA PEKERJAAN DAPAT DILAKSANAKAN DENGAN AMAN DAN SETUJU UNTUK MEMATUHI SEMUA KETENTUAN YANG TERTULIS DI IJIN INL dee | Gh Name Nene ae Tine enw wor | Larne | Sunconiacr Supeniear POP FSEPOP ‘General Superntendent? | Gent Representaive | | Representatve Construction Manager JOB FINISH OR EXTEND / PEKERJAAN SELESAI ATAU DITUNDA-- T Acbopt tho work (Completed / Extend), Work Piace Has been | Fnaored by] clean and safe Yee /Pekeran | Dete/Terggsl) Time/Y8m | Saya menerima pekerjaan (selesai / ditunda/diperpanjang)’, ae | Tempat kerja telah kembali amen dan bersi, {= Trini Sotesai | fEdend /Otundal | eee gy ee pe i | Sort i So te See ane; | sume Nene. Name Name Se3 See Se Reset a 1 core euro suvcontactr operant | chant | Reposenatve | Superianrpoe | _HS€ POP on Represeniabve