Classification: Internal

13/12/2022

PERMIT TO WORK ACCESS FORM

Date of Request: 12/12/2022 Tracking No.: 2022_5508
□ Asset Contractor □ Tenant Contractor □ Marketing Contractor
Any person/company trying to gain access to The Mall is required to pre- arrange access and obtain approvals from Mall Management and Security Department.

A Contact Details - Originator

A1 Store/Brand Name: ROXY CINEMA THE BEACH A4 Contact Person: ANGELINE MANUEL
A2 Holding/Company Name: MERAAS / DUBAI HOLDING A5 Telephone No.: 045905106
A3 Job Location: ROXY CINEMAS THE BEACH Shop Unit No.:
B Contact Details – Permit User
B1 Main Contractor/Supplier Name (same as Trade License Veristar Building Contracting LLC No of Workers: 1

B2 Subcontractor name and details (if any) Fairways Building Contracting LLC No of Workers: 4
B3 Contact Person Name: Emad Yosry B4
Contact number: 0558664544
B5 Safety Supervisor Name: Jovin Mathew B6 Contact number: 0554501207
B7 List of Subcontractors: Fairways Building Contracting LLC No of Workers: 4

C Request Details:
C1 Date From: 12/12/2022 To: 12/01/2023 General Permit Duration: ………
Hot Work: 12 hours
C2 Time From: 3 AM To: 3 PM High Risk: 12hours
C3 Work Description: (Attach Method Statement)
1. Removal of the existing Door
2. Fixing new Door - As per existing design
- No noisy works during Mall trading hours
1. Permit is intended for the stated scope only, no other work is permitted.
Mall Management Comments: 2. Safe working procedures to be followed at all times.
3. Permitted ladder use up to 2 metres maximum.
4. Work to be carried out by competent personnel and under competent supervision.
5. HSE supervision is the responsibility of the contractor and are liable for any mishaps.
6. PPE is mandatory as required.
C4 Type of Work
Any violation or deviation from stated scope will result in immediate termination of permit.
(a)General (b) Hot Works (Required to Fill Hot work (c) High Risk Activities (Required to Submit MSRA and required
□ Window Display permit form Appendix A and submit MSRA and safety certificates)
□ Merchandise required safety certificates) □ Working at height – Ladder only
□ Branding □ Welding □ Working at height - Scaffolding
□ Delivery □ Gas / flame Cutting □ Working at height - MEWP (boom, Manlift, scissor lifts).
□ Stock/Take inventory □ Waterproofing □ Confined space –
□ Cleaning □ Metal Grinding/Cutting □ Electrical LV
□ Painting □ Others, please specify □ Electrical HV - Isolation
□ Duct Cleaning □ Lifting work (using lifting equipment/ heavy vehicles)
□ Shop Front Signage □ MEP work
□ Pest Control □ Structural Erection – Events Set up
□ Fire alarm/fighting maintenance □ Heavy Vehicles entry (Crane, excavator, forklift, drill rig etc)
ü
□ Others, Please Specify □ Work affecting Evacuation routes
Replacement of existing door □ Chemicals – Hazardous substances
□ Isolation (MEP, Electrical, Gas,)
□ LPG maintenance
□ Pressure testing
□ Demolition
□ Others, Please Specify
C5 PPE Required (Please select the ones that are applicable and will be provided)
ü
□ Safety Boots / shoes
□ Hard hat
ü
□ Gloves (Specify type)
ü
□ Dust mask / respiratory protective equipment
□ Fall arrest Harness
□ Eye protection
□ Ear defenders
□ Reflecting vest

C6 Documentation Submission requirements

□ Tenant/Contractor Trade License □ Governmental Permits/Trade License & Labor ID □ 3rd party certification
□ Layout/Location Map □ Risk Assessment □ Insurance
 □ Method Statement □ Security Deposit
Classification: Internal □ Relevant Safety certificates

Merex HSE comments:

• Contractor will ensure all precautions above are maintained at all times
• All Firefighting protection equipment will be safe for use and inspected
• Staff involved in the task will be competent and monitored at all times
• Supervision will be deployed for the full duration of the activity
• Contractor accepts full accountability/liability for the Hotwork activity and its staff compliance
F Terms and Conditions – Please read carefully
F1 The company and number of workers mentioned will only be permitted to access the mall.
F2 Approved and signed Work Access Form must be with the Contractor / Staff at the time of entry / work. The Security Department and Mall
Management reserves the right to review this permit at any time.
F3 This form only grants access to staff and contractors outside of Trade Hours.

F4 All kinds of waste generated by the work activities will be disposed of by the contractor.
F5 Tenant and Contractor are fully responsible for ensuring the operation is carried out safely and the workplace is safe for anyone that may be
affected.
G Approval Status – to be filled by Mall Management Team & Contractor
Permit will be suspended and re-issued after one of the following scenarios has occurred: PTW Acceptance by Signature
Contractor
• One work shift, with a maximum time of 12 hours, has ended (for Hotwork).
• When the work plan deviates from the original plan
• If work scope changes Note:
• When there is a change in the personnel involved - Permit is intended for the stated scope only
- No High risk work allowed
• Whenever an emergency/evacuation alarm is sounded - Competent person to carry out the manual handling work.
• Any noisy work during operation hours - Work area to be barricaded/signage to be placed
- ensure use of PPE
- Work area ro be cleaned well after completion of work
Parking Validation: YES NO

Pre-Approval of MSRA by HSE Department (For Hot works & High-Risk Works)
Jeston Nelson
Name: _________________________________________ Signature: ______________________________________
Department: HSE

Completion Management
FM Department / Marketing / RDD: _______________________ Signature: _____________________________ Of work Signature
Samuel Lenny
Mall Management: ______________________________ Signature: ________________________________________

Approval Stamp:

Cancellation

Date:
Work Access Form must be submitted by email, 72 business hours before the work takes place. Tracking No.:

SPECIFIC HSE INFORMATION AND RULES

The Staff/Tenant/Contractor shall adhere to the following Health, Safety & Environmental rules listed below. Inclusive of, but not limited:
1. Obey all local authority HSE rules and regulation;
2. Employer should, by law, need to provide Personal Protective Equipment (hereafter referred to as ‘PPE’) to their workers, i.e. hard hats, gloves, high visibility
vests, safety Harness, Safety Shoes etc. Make sure workers are using them;
3. The correct PPE must be worn at all times, Additional PPE will be required in accordance with individual Method Statements and COSHH recommendations;
4. Work in accordance with accepted safety practices, not to take chances;
5. Report unsafe working conditions and/or practices to supervisors immediately;
6. Use correct and suitable tools, and ensure proper care is taken;
7. Obey instruction from the HSE and Security team always;
8. All works shall be carried out as per approved Method statement and Risk assessment and competent supervision;
9. Portable electric tools and equipment shall only operate with adequate safety measures such as safety guard, proper electrical cables and PPE. All electrical cables
and connections shall be secured at all times;
10. Proper House keeping must be followed;
11. Ensure adequate barricading and signage in the work area until the work is complete;
12. Anybody found to be under the influence of alcohol or drugs will be penalised and removed from the property.
13. Fighting, Horseplay or other unprofessional actions which put other people’s safety at risk will not be tolerated. The use of abusive language or making excessive
noise is prohibited, also;
14. Smoking is prohibited except in specifically designated smoking areas. Any person found smoking in restricted areas is liable to be permanently removed from
the property and to be penalised.
15. Approved Work Access form must be submitted to security department prior to the start of work and No any work shall be carried out with out any approval,
16. Copy of the work permit shall be placed in the work place or presented to the HSE/Security personnel upon their request;
 17. Contractor pass shall be acquired from the Security office prior to the start of work and must be returned back after the work completion; and
Classification: Internal
18. In the case of any emergency, Contact Security team –
19. Ensure all COVID protocols are adhered too, No sick staff allowed to work on the site.
20. All preventive measures for COVID control must be implemented by the company for works conducted on site at the asset in compliance with the legal guidelines.
I read the above instructions and will brief our workers to ensure they strictly abide by the above rules and regulations.

Name : Aparna T RANGELINE MANUEL Organization Veristar

: ROXYBuilding Contracting LLC
CINEMA CITYWALK
Signature : Contact No. 0589356412
:045905103