OKI PULP & PAPER MILLS Document No.

HSD-S3-0006
Revision 01
LIFFTING WORK PERMIT Page 1 of 2
In case of emergency the permit will be considered invalid.
Issue Date 16-Jun-17
Permit No.: Permit No.: OPP/H&S/PTW/2017/__________ General Permit Reference No.
A Time Schedule
Start Date: 2023 Finish Date: 2023
From (hh:mm): 07.30 To (hh:mm): 16.30
≤ Non-working day ≤ Day shift ≤ Night shift
Company Name : __________________________ Permit Holder Name: ___________________________
B Location And Activities
Work Areas / Components of plant:

Liffting Sport Center

Activities to be executed: 1. Liffting / Erection tower 5

(to complete work) 2 6
3 7
4 8
C Measure
C1 Safety Controls as defined in (all documents MUST be attached to the work permit):
Yes No

≤ Job Safety Analysis (Name, doc.no., revision, date)

≤ Liffting study (Name, doc.no., revision, date)
≤ Other (Name, doc.no., revision, date)
C2 Documents to be checked - Prior commence of work Comments & Definitions
Name
≤ Crane driver certified :
Driving Licence
≤ Crane certificate : Certificate Validity
Insurance No.
≤ Crane insurance :
Validity
≤ Lifting tools & tackles : Certificate Validity
≤ Daily checklist : Inspected By

C3 Additional Safety Controls - During work

≤ Lifting plan calculation
≤ Crane pad / Out rigger based plate
≤ Barricade and safetysign
≤ Rigger and Signalman
≤ Tag line

C4. Additional Safety Controls - Emergency Rescue Plan

1. PIC Dominggus Belo
Emergency Contact Number 2. Shift Leader Wawan Iyet
3. Health & Safety Yogi Oktaberto
C5. Additional Safety Controls - After work
1.
2.
3.
 OKI PULP & PAPER MILLS Document No. HSD-S3-0006
Revision 0
LIFFTING WORK PERMIT Page 2 of 2
In case of emergency the permit will be considered invalid.
Issue Date 16-Jun-17
D. List of authorised personnel (if special education/training or further personal prerequisites are required)
Name / Badge-ID or similar
1. Wawan Iyet 5.
2. Yuda Nugraha 6.
3. Soni Nuraripin 7.
4. 8.
E. Work authorisation following an inspection of the work site before commence of work
1. Permit has been reviewed and accepted by PT. OKI HSE Department

M. Hasbi
Date Name Signature
2. Permit has been reviewed and accepted by COMPANY (Permit Endorser)

Date Name Signature

3. Definition of safety precautions and work permit by COMPANY (Permit Issuer)

Dominggus Belo
Date Name Signature
4. Defined safety precautions agreed and accepted by CONTRACTOR (Permit Holder)

Ahmad Januari
Date Name Signature

F. Daily confirmation that the conditions are unchanged and controls are still in place following an inspection of the work
site before commence of work
Date
1. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
2. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
3. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
4. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
5. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
6. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
7. workday :
Shift Leader Process Electrical Mechanical H&S PIC
G. Notice of completion of work and closure of work permits

Date Shift Leader Process Electrical Mechanical H&S PIC

H. Completion Inspection By
≤ Notified and accepted by PIC.
≤ Notified and accepted by Shift Leader.
≤ Notified and accepted by Process Dept.
≤ Notified and accepted by Electrical Dept.
≤ Notified and accepted by Mechanical Dept.
≤ Notified and accepted byHealth & Safety Dept.