Quadunion Builders Pte Ltd

PERMIT TO WORK 施工准许证 - ____ CONFINED SPACE_________

(THIS COPY SHALL BE DISPLAYED AT PLACE OF WORK, AS APPROPRIATE)

PROJECT TITLE（项目名称 ）: _____________________________________________________________________

APPLICANT COMPANY（申请公司名称 ）: ___________________________________________________________
NAME OF APPLICANT（申请人姓名 ）: Mr / Ms（先生/小姐 ）_________________________(Delete as appropriate 删除相应的)
WORK TO BE PERFORMED ( 所申请的施工类型 ）:____________________________________________________
DURATION OF WORK / DATE & TIME（施工历时/日期与时间）: From（从 ）___________ to（至 ）___________
LOCATION OF WORK（施工地点 ）: _________________________________________________________________

This Permit-To-Work (PTW) is valid only for the duration stated above. The conditions of issue must be complied with
throughout the duration of the work, otherwise, this PTW can be withdrawn at any time. The applicant of this PTW shall be
responsible for maintaining a copy of this permit and must produce it upon request.
SAFETY CONDITIONS TO BE COMPLIED WITH PRIOR TO PERMIT APPROVAL.
SAFETY CONDITONS  /  / NA
1. Workers have attended SOC for manhole workers
2. Workers are briefed on entry and emergency procedures
3. PPE provided - safety harness, lifeline, respiratory protection, etc.
4. Attendance signboard at entrance is available
5. Watchman has been assigned at entrance of confined space
6. Place purged and ventilated
7. Gas test done with atmosphere deemed safe for entry to work
O2 reading = __________ % Combustible gas (CH4) reading = _______________ % LEL
Toxicity gas (CO, H2S, CO2) reading = ____________ ppm Type(s) -
8. Force ventilation provided at ≥ 1.4m³/min per person
9. Rescue equipment tested
10. Electrical tools of flame proof and approved type
11. Exhaust from internal combustion engines directed away by a qualified person
12. Work requiring work platform / ladders is accordingly provided
13. Lock-out and tag-out procedure complied for maintenance works

Permit Application By Supervisor / Person Responsible for Confine Space Work:

I fully understand the nature of the work and safety conditions that must be met. I have inspected the
safety conditions relating to the work to be performed.
Name & Signature : __________________________ Company : ________________________
Date / Time : __________________________ Position : ________________________
Inspected By Confined Space Assessor:
Name : __________________________ Signature : _________________________
Date : __________________________ Time : _________________________
Result : SAFE / UNSAFE
Permit Verification By WSHO / Safety Assessor:
Name : __________________________ Signature : _________________________
Date : __________________________ Time : _________________________
Permit Approval By Project Manager:
Name : __________________________ Signature : _________________________
Date : __________________________ Time : _________________________
Notification of Work Completion by Applicant: The work area has been checked and cleared if
equipment, tools, waste materials, etc.

Name : __________________________ Signature : _________________________

Date : __________________________ Time : _________________________

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Further review and approval (at 3 hours intervals) while the permit is in force:

Time / Sign Time / Sign Time / Sign Time / Sign

Inspected by: _____________ _______________ ______________ _____________

Approved by: _____________ _______________ ______________ _____________

　 　 　 　 　 　 　 　 　 　 　 　 　

Safety Briefing
1 No persons shall enter the confined space unless the confined space is certified safe for entry by the Confined Space
　 Safety Assessor. 　
2 For any hot work or spray painting, apply for Hot Work Permit to seek approval prior to work commencement in confined space
3 No smoking or naked flame is allowed inside the confined space. 　
4 Cigarettes and lighters and any other sources of naked flames must be surrendered to watchman before entering the
　 confined space. 　
5 At least two workers must be engaged at any time inside the confined space. No one is allowed to work alone.
6 All personnel must put on the appropriate and suitable personal protective equipment for working inside the confined space.
7 Upon expiry of permit and during lunch, tea-break, rest time or after work completion, all personnel must leave the confined
　 space immediately. No one is allowed to rest or stay inside the confined space.
8 No consumption of food is allowed inside the confined space. 　
9 Use proper access provided for means of access to and egress from place of work in the confined space. 　
10 Do not remove any safety measures( blower, trunking or access) installed inside the confined space.
11 No horse play is allowed inside the confined space. 　
　 　 　 　 　 　 　 　 　 　 　 　 　

NAME LIST OF WORKERS WORKING IN THE CONFINED SPACE

　
We are briefed and made aware of the hazards and precautionary measures that must be undertaken and
complied with when working in the confined space. 　
　

S/No Name of Worker Signature

1 　 　
2 　 　
3 　 　
4 　 　
5 　 　
6 　 　
7 　 　
8 　 　
9
10
11
12
13
14
15
　 　

Safety Briefing Conducted By : ___________________________________________________________

　 Name / Signature / Date of: WSHO / Confined Space Safety Assessor / Safety Assessor
　 　 　 　 　 　 　 　 　

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