Dubai Healthcare City

Permit to Work
PTW Permit Start Date / Permit End Date Approved Time of Work
No:

DHCC/PTW/HSE/
Date: 11-12-2022 Date: 11-12-2022 From: To:

Time: 08:00 Time: 20:00

Stage 1: Performing Authority (Application by Service Provider/Tenant /Contractor)
Contractor/Service Provider Sign:
Name: Al Mukhathat Tech Cont.
Contact Number
+971 55 697 1696 Time:
11:23
Location of Task: No of
Amico DHCC employees 3
Task: (Tick the appropriate box)
1. Work at Heights (Above 2m and work on roof tops)
✓ 7. Demolition / Renovation fit out (CPQ approval for internal
work)
2. Hot work 8. Work involving penetration into structures
3. Work in confine space ✓ 9. Use of toxic / flammable material (Spray Painting
4. Work with pressurized equipment’s 10. Mechanical lifting (Use of cranes and MEWPs)
5. Excavations 11. General high risk potential works (Specified works)
6. Work with energized services (Electrical ) ✓ 12. Others (Minor works, Access to facility rooms,)
Measures Yes No N/A
1. Job specific Risk Assessment and Method Statement/Task Procedure attached ✓
2. Test certificates, Approvals, Licenses, Checklists, Fit out permit etc. are attached
3. Requirements identified with Activity based Checklist are attached and in place
4. Isolation of MEP/fire systems required and/or restricted area / time (Isolation tag issue)
Tenant /
Designation Date
Client Name

Signature Contact No. Time

Stage 2: Issuing Authority - Approval by DHCA FM / HSE

1. FM Service Provider Name: Designation: Sign: Date:
Remarks / Comments /
Observation:

2. DHCC HSE Name: Sign: Date:

Designation: Contact#: Time:

Remarks / Comments /
Observation:

3. DHCC FM Name: Sign: Date:

Designation: Contact#: Time:

Remarks / Comments /
Observation:

Issued on: 10 June 2012 Revised on : 14 November 2019 Revision: 6.0 Page: 1 of 4
DHCC HSE, PO: 66566, Phone: +971 4 3622816, Direct:+971 4 375 9823, Email: HSE@dhcc.com
 Dubai Healthcare City
Permit to Work
Stage 3: Security Access Control
PTW Issue / Access to site No. of Passes issued: Pass / Isolation tag details:

No of Isolation tag issued:

Name Designation Date
Signature Contact No. Time
No of passes collected: Pass / Tag details:
PTW Close Out / Exit from
Site:
No of isolation tag collected:
Name Designation Date

Signature Contact No. Time

Stage 4: Work Completion / Stoppage / Cancellation (Issuing Authority / Performing Authority / Security)
Brief description for work stoppage:

1. Applicant (BP, Contractor Name: Sign: Date: Time:

/Service Provider)
2. Facility Inspector / CPQ Name: Sign: Date: Time:
Design & Eng. Service:
Remarks / Comments /
Observations:
3. Issuing Authority Name: Sign: Date: Time:
(Campus Management / HSE:
Remarks / Comments /
Observations:
4. Security: (To be signed Name: Sign: Date: Time:
when stoppage of work)
Remarks / Comments /
Observations:

Permit Extension / Modification:

Sr. Extension / Modification Period Issuing
No From: Date / Time To: Date / Time Authority Applicant Sign Reasons for Permit Extension / Modification:
Sign
1

Description / Scope of Work

Dismantling of ac units

Access Arrangement (Details of any special access / egress requirements)

Issued on: 10 June 2012 Revised on : 14 November 2019 Revision: 6.0 Page: 2 of 4
DHCC HSE, PO: 66566, Phone: +971 4 3622816, Direct:+971 4 375 9823, Email: HSE@dhcc.com
 Dubai Healthcare City
Safety Documents –Permit to Work
Permit to Work Systems
Permit to Work System is a formal written system used to control operational tasks by DHCA in the premises of
DHCC. It is an essential document which systematically defines how work is to be done, the location, personnel
responsible to apply, endorse and approve, date and validity of the permit as well as the necessary precautions to
be taken to reduce the risk to as low as reasonably possible.
A permit to Work is required for the contractor to follow safe system of works as mentioned below including minor
works and access to facilities:
• Working at Height (Above 2 meters)
• Work on Roof Top
• Demolition/Renovation (Fit Out approval for internal works)
• Isolation/Tag Out/ Lock out of Services
• Work in Confined Space
• Hot Work
• Mechanical Lifting Devices (Use of cranes and MEWPs)
• Work in restricted area (Medical Gas Areas / Laboratory /Radiation (Infrared/ Ultrasonic/ Microwave / EM /
Radio Active) Areas
• Use of Toxic/ Flammable Materials
• Use of Chemicals, Compressed Gases and Hazardous substances
• Work with Pressurized Equipments
• Deep Excavation/ Deep Penetration into Structures
• Electric Works
• Work on Scaffolds
• General high risk potential works (Specified works)
• Work with energized services (Electrical)
• Others (to be specified.)

Safety Documentation
Prior to any site works, all business partners must ensure that the contractor has the complete list of supportive
documents, based on activity requirements.
A Permit (PTW) for all works including major fit out works/ construction works may require the contractor to provide
the following documents to the Building Manager / Facility Manager, as follows (below list if not an exhaustive list,
dependant on site works):
• Final Design / Architect’s Drawings (if required)
• Evidence of Site Assessment (if required)
• Site specific Risk Assessment
• Job specific Method Statement/Task Procedure that provides:
o Scope of Work
o Roles and Responsibilities for the task
o Site Safety Measures
o Equipment’s/ Tools to be used
o PPE requirements
o Evidence of Tool Box / Induction Training / Communication
o Emergency/ Evacuation Procedures
o Awareness with Security Procedures

Issued on: 10 June 2012 Revised on : 20th October 2019 Revision: 6.0 Page: 3 of 4
DHCA HSE, PO: 66566, Phone: +971 4 3622816, Direct:+971 4 375 9823, Email: hse@dhcc.com
 Dubai Healthcare City
Safety Documents –Permit to Work
o Vehicle Safety
o Infection Control/ Dust
o Noise Management
o Waste Disposal
• Safety Declaration
• Contractor’s License and Insurance Policy
• Isolation of MEP/Fire systems required and/or restricted area / time (Isolation tag issue)
• Competency/ Appropriate Training Certificates (where appropriate)
• Test certificates, Approvals, Licences, Checklists, Fit out permit etc. are attached
• Maintenance Records
• Evidence of PPM and Test Certificates for Machinery (if required)
• Equipment Load Calculations (if required)
• Civil Defence Certificates (where appropriate)
• Dubai Municipality or DEWA Approvals (where appropriate)
• Material Safety Data Sheet for all chemicals used at site
• Evidence of Fire Proof Storage for flammables
• COSHH for hazardous substances (Control of Substances Hazardous to Health)
• Fire Fighting Equipment’s (if required)
• Isolation Tags (if required)

References
• DHCC HSE Contractors Safety Policy
• DHCC Contractor Safety Code
• DHCC Permit to Work Procedures
• DHCC HSE Method Statement and Risk Assessment Format
• DHCC HSE Isolation Tag Format
• DHCC HSE Checklists
PTW Applicant Declaration:

I hereby agree to the following PTW terms and conditions:

1. This permit is deemed to be cancelled on any change of conditions and/or safety or other violations at site. The applicant
is fully liable for the penalties/rectification/cost implication of any damages or consequential damage and accidental
injuries / fatalities resulting from the activities/interruptions caused in order to carry on with the works.
2. Copy of NOCs and Valid permit must be available in the vicinity of the job for verification during inspections
3. The permit to be submitted for renewal / extension before the expiry date and the renewal / extension is subject to the
evaluation of the work status by Issuing Authority
4. If the job involves multiple tasks such as Confined Space, Height Work, Hot work, Services Isolation, Excavation etc.
relevant checklists must be completed and accompany the permit
5. Maximum validity of Permit to work in Confined space should be 24hrs and applicant is responsible to renew the permit.
6. Activities having the potential to create nuisance (Noise, Odor, Waste, Dust, Alarm activation, material transfer etc.) to
other business operations have to be carried out between 1900hrs to 0600hrs after ensuring all necessary controls are in
place and will be stopped if nuisance persists.
7. Secure approval from Leasing fit out and Design department for modification works involving floor layout design change
/ alteration.
8. Copies of Fit out permit and approved related drawings and documents to be submitted along with the PTW for the
review by Issuing Authority.

Salahudeen
Applicant Name: _______________________________ 09-12-2022
Sign: __________________________ Date: __________________

Issued on: 10 June 2012 Revised on : 20th October 2019 Revision: 6.0 Page: 4 of 4
DHCA HSE, PO: 66566, Phone: +971 4 3622816, Direct:+971 4 375 9823, Email: hse@dhcc.com