Project No.

P-OkiPL1
OKI PULP & PAPER MILL PROJECT
Document No. P-OkiPL1-100-15-FRM-000
[ FORM - OKIPL1] Revision 01
WORK AT HIGHT PERMIT Page 1 of 2
In case of emergency the permit will be considered invalid
Issue Date 20-Oct-16
Permit No.: Permit No.: OPP/H&S/PTW/2017/_______ General Permit Reference No.
A Time Schedule
Start Date: Finish Date:
From (hh:mm): 07.30 AM To (hh:mm): 05.30 PM
≤ Non-working day ≤ Day shift v ≤ Night shift
Company Name : PT.Kota Minyak Permit Holder Name: PT. Kota Minyak Internusa - Ahmad Januari
B Location And Activities
Work Areas / Components of plant: Sport Center
At Higtht. Approx. 20-80 Meter
Activities to be executed: 1. Prepare material and tools 3. Pengecatan tower
(to complete work) 2. Pemasangan tower 4.
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) V

≤ Other (Name, doc.no., revision, date)
C2 Additional Safety Controls - Prior commence of work Comments & Definitions
≤ Use ladder V
≤ Use of Mobile Elevated Work Platform
≤ Use scaffold
≤ Use of mobile scaffold V
≤ Use work basket V
≤ Safety nets required V
≤ Conduct load test on anchor device (100 kg) V
≤ Erect signs and barriers V
≤ Medical test for work at height V
≤ Define / arrange anchor device (>10KN) V
≤ Ensure clearance to overhead power lines ..... Meters V
≤ Use full body harness V
≤ Use lanyard V
≤ Use double lanyard V
≤ Use energy absorber V
≤ Use guided type fall arrester
≤ Use retractable type fall arrester
≤ Cover openings
≤ Install hard barricading / guardrail V
≤ Working close to waterbodies V
C3 Additional Safety Controls - During work
≤ Use of tool box kit for tools V
≤ Housekeeping V
C4. Additional Safety Controls - Emergency Rescue Plan
1. PIC Musa B.M
Emergency Contact Number 2. Shift Leader Dominggus Belo
3. Health & Safety
C5. Additional Safety Controls - After work
1.
2.
3.
4.
Project No. P-OkiPL1
OKI PULP & PAPER MILL PROJECT
Document No. P-OkiPL1-100-15-FRM-000
[ FORM - OKIPL1] Revision 0
WORK AT HIGHT PERMIT Page 2 of 2
In case of emergency the permit will be considered invalid.
Issue Date 30-Jun-15
D. List of authorised personnel (if special education/training or further personal prerequisites are required)
Name / Badge-ID or similar

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)

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.