Doc CMEC-HSE-PR-

No. 15-F-009
Permit To work Form
Rev No. 00

PTW Control No Date /

Location & Coordinates Shift Day / Night
MS & RA Ref number Project Name / Company PV2 CCEED -MMC
Name of Permit Receiver Waqas /Amir Designation of Permit Receiver Site Engineer
Contact Number (Mobile) 0525868034 / 0 52 799 6937 Emergency contact information 0554264700/0544623146
Sub-contractor HSE
Name of Permit Issuer Awais Designation of Permit Issuer MEP Engineer
Contact Number (Mobile) 0553993640 Emergency contact information 0568969448
CMEC HSE
Employee In-charge at work Number of Employees working at site
site & Contact Number
Plant & Equipment’s used
Permit valid from (Date) __________ (Time) ___________ hrs. to (Date) ___________ (Time) ____________ hrs.
Type of work permit required Cold Work Permit Excavation Permit Critical lifting permit
Hot work Permit Electrical Permit
Description of Job

Requested by Sign: Date & Time Approved by : Awais Sign: Date &
(Permit Receiver) (Permit Issuer) Time
Remarks Remarks

Acknowledged by CMEC Sign: Comments:

PTW coordinator
Name: Date & Time:
Hazards of Worksite - Field Assessment by Sub-contractor HSE
Collapse / fall of load / Excavation associated
Restricted access & Egress Slip or trip Heavy Manual Handling
material hazards
Fire Hazards Heat or cold Struck by object Waste generation Fall from height

Electrical hazards Noise Rain / Mist Isolated work Dangerous specious / insects
Mechanical hazards Illumination Dust / Sand storm Vehicle Movement Vehicle movement
Additional HSE Hazards if any assessed on field (To be field by Sub-contractor HSE):

Hazard Controls Required -Field Assessment by Sub-contractor HSE

PPE compliance Waste segregation & house
keeping
Sloping / benching / shielding Effective illumination
Dust control measures Noise control Measures
Effective barricading & Lifting Plan (Additional sheet
Signage’s required)
Fire prevention & Protection Lock out / tagout (Additional
measures sheet required)
Standard scaffolding & ladders First Aid Kit & first aider Appropriate material stacking &
storing
Water, Rehydration drinks Desert Kit Competent supervision
Waste management Training and awareness Vehicle inspection / maintenance
Emergency standby vehicles Cable Management
Buddy system Fall protection &
Prevention

Additional HSE mitigation measures initiated on field (To be field by Sub-contractor HSE)

Declaration by Lead Work Party & Sub-contractor HSE

Hereby we confirm that, safety mitigation measures as declared in risk assessment as well as through this permit is implemented and continuous monitoring of the same shall be
ensured for its sustainability.
Sub-contractor Lead work Ahmed Ali Date & Sub-contractor HSE Name & Hany Othman Date &
party Name & Signature Time Signature Time

Permit Renewal by Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Start End Start End Start End Start End Start End Start End Start End
Permit receiver Time Time Time Time Time Time Time Time Time Time Time Time Time Time
Date
Signature

Permit closure on job completion / permit expiry

Permit Receiver CMEC Permit Issuer
Name Waqas Signature Name Awais Signature
Date: Time: Date: Time:
Stop work notice by CMEC or Client
Reason for Permit Cancellation: Name & Signature with date:

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