MVL-HSE-ANCD-ELITE

Room Permit to Work IssueAT

PERMIT VALID FOR ONE 8 HOUR SHIFT ONLY. PERMIT SHALL REMAIN Date: Permit OF
WORK AREA FOR DURATION #: JOB.

Section 1: Details of work: Date: ___________________

Location of work on site:

No of workers involved: TRADE:

Details of work to be undertaken:

Starting Time: Planned Finish Time:

Section 2: Before work commence:

1 Alternative entry and exit point identified and proper housekeeping already done. Y N

2 Area of work commencement is safe prior to work? Y N

3 All workers have been briefed of the activity to be carried out? Y N

4 All safety requirements have been put into consideration and fulfilments? Y N

Section 3: Checklist undertaking by the recipient:

This permit is activated at the time the permit recipient signs section 4 and its valid for the period of work defined in section
1

Proper housekeeping and segregation of materials must be done as soon as current work is finished.

Workers starting this work must be briefed about the safety procedure during and after the work.

All safety procedures must be followed

The recipient is solely responsible for his work and safety of his worker till expiration of permit.

Section 4: Permit declaration:

I have gone through the pre work permit requirements in accordance with section 3 of this permit and confirm that the work
area is safe as stated in section 2 and will provide a close supervision during my works.

Permit Recipient Name Signature

Designation Date/time

Permit Issuer Name Signature

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 MVL-HSE-ANCD-ELITE
Room Permit to Work IssueAT
PERMIT VALID FOR ONE 8 HOUR SHIFT ONLY. PERMIT SHALL REMAIN Date: Permit OF
WORK AREA FOR DURATION #: JOB.

Designation Date/time

Safety comments to be complied with:

Snr Eng./ PM Signature

VERIFICATION/ CANCILATION BY: Site IN-CHARGE: Signature

HSE Department MVL Inc. AUAB

NOTE: This permit will be issued only upon request and be submitted each day after work and will be verified if it’s in
compliance with cleaning and segregation of materials in a safe manner and all safety procedure Be implemented.
FAILURE TO COMPLY WITH THE STATED EXPECTATION WILL RESULT TO A FINE ON THE PERSON WHO
REQUESTS THE PERMIT, AND PERMIT FOR NEXT DAY WILL NOT BE ISSUED UNTILL ALL MEASURES OF
PREVIOUSE IS COMPLIED WITH.

Attendees
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Eemergency Contact No: 74457552 HSE Officer Mobil No. 30599503, 77727464

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