PERMIT TO WORK

A. Applicant ( to be completed by HAS Supervisors / Contractors) Permit No.:

General Confined Space Critical Lifts Hot Work Excavation Electrical Working at height
□ □ □ □ □ □ □

Location Requesting Company Date

Requested by : Manpower Type of Tools Tick

(Person in Charge) Required Machinery
Electrical
Work Activity
Hand Tools
B. Precaution to be taken prior to commencement and during the work
Safety Precaution Yes N/A Safety Precaution Yes N/A
1 Appropriate PPE 9 Signages
2 Fall Protection 10 Adequate ventilation
3 Fire Extinguisher 11 Gas Monitoring
4 Fire Blanket to Arrest Spark / Flame 12 Breathing Apparatus
5 Pipeline Purged 13 Adequate Lighting
6 Access / Egress 14 Underground Utilities Identified
7 Shoring 15 Job Hazard Analysis
8 Guardrails / Barricades 16 Other (if any)
Other Safety Precaution required please specify

C. Permit Issuer ( to be completed by Working Partners / Contractor )

Permission is given for the work to proceed subject to the conditions specified above Type of Work/Permit Tick
From Date: Time: Site Manager General ( 7 days)
To Date: Time: HSE Manager Critical ( 12 hours )
Permission is given for the work to proceed subject to the conditions specified above
Permit Validity 7 days ( to be renewed daily by Working Partners / Contractor )
Day / Date Approved by Site Manager / HSE Manager

D. Performing Authority Acceptance ( to be completed by HAS Supervisors / Contractors )

I certify that I have read and understand this permit and that the work will be carried out in accordance with the requirements.
Name Signature Date Time Company
Signed
(Responsible Person)

Transfer of Responsible Person

E. Completion of Work ( to be completed by HAS Supervisors / Contractors )
I hereby declare that all work for which this permit was issued has been completed, all personnel under my control have been withdrawn and the work area and all associated
equipment has been left in safe condition.
Name Signature Date Time Company

Signed

F. Cancellation ( to be completed by Site Manager / HSE Manager )

This permit is cancelled.
Name Signature Date Time Company
Signed
(Responsible Person)
Original ; Permit Applicant
2nd copy ; Permit Issuer
3rd copy ; C-HSSE Dept.
4th copy ; C-HSSE Dept. upon PTW Issuance