CGPV INDUSTRIAL BUILDING SYSTEM SDN BHD DOC NO.

CHECKLIST A4

REV. : 00
PERMIT TO WORK
DATE : 8TH FEBRUARY 2021

LIFTING OPERATIONS PERMIT-TO-WORK DATE : _20/03/2023__________________

Contractor: LONG TENG CONSTRUCTION

Location of work: PHASE 2
Description of work: FORMWORK, BRC, CONCRETE LIFTING WORK
Permit validity period: 20.3.2023

PART A – Application by Lifting Supervisor-in-Charge:

I have checked (tick where applicable) and confirmed that the following requirements have been complied with:Lifting plan
communicated to lifting crew.
Crane operator (Name): ZAMZURI BIN HASHIM_____ carried out inspection of crane.
Lifting machine & equipment checked and found in good condition.
Load radius indicator, warning lights, horn and all limit switches in good working condition.
Correct Crane Load Chart used and understood by all.
Inspection carried out using the daily checklist for crane access
Work area cordoned off to prevent unauthorized access.
Competent Rigger (Name): _____SADEKY___________________
and Signalmen (Name): _SADEKY__________________ appointed.
Lifting crew properly attired according to Ministry of Manpower guidelines.
Lifting Supervisor carried out inspection prior to commencement of works.
Toolbox briefing is carried out prior to commencement of works.
Safe Work Procedure (SWP) is available and briefed prior to commencement of works.
Risk Assessment (RA) is available and briefing carried out prior to commencement of works.

I (Name): NOR AZHAR BIN ABDUL undertake to check the above conditions of permit regularly and ensure that the work
is safe throughout the duration of Permit-To-Work and will stop the lifting operations should conditions become unsafe /
hazardous / incompatible.
Date: ___20/03/2023______________ Time: _9.00AM________________ Signature: _______________

PART B – Assessed by Appointed Safety Assessor:

I have inspected the above-stated location and confirmed that the recommended safety measures are in place and the said location is safe for
work at the point of inspection.

Name: _SURENDREN A/L KRISHNAN________________________ Designation: __SSS____

Date: __________20/03/2023_______ Time: ___9.00AM______________ Signature: __ ______

PART C – Verified by IBS Engineer / Supervisor In-charge of Work:

I am satisfied that there has been a proper evaluation and there are no incompatible activities at point of my review.

Name: K. ESWARAN_______________________________ Designation: SENIOR HSE EXECUTIVE________________

Date: _____20/03/2023____________ Time: ___9.30AM______________ Signature: ____________________

PART D – Approval by Appointed Project Manager / Overall in-charge:

I am fully satisfied that all reasonably practicable measures have been implemented and a thorough inspection and proper assessment of the
work area and its surrounding has been made so that the work can be carried out safely.

Name: Mr. Jorson_______________________________ Designation: Project Manager____________________________________

Date: ________20/03/2023________ Time: __9.30am_______________ Signature: ____________________

PART E (tick one)* – Notification of Work Completion / Cessation of Work:

I confirm that the above-stated work was completed safely on __________ at __________ hours.

The above-stated work was stopped on ____________ at __________ hours due to unsafe conditions.
Name: _______________________________ Signature: ____________________________________