Ref: DWE-COS-HSE-TMP-00128

Rev: A.3
Limitation of Access Date: 20-MAR-2023
DWMC Project Page: 1/1

LOA NUMBER:
PART 1 – Activity information
Company: HZI RAMS Reference: CMR-SKO-ME000380
Start Date 8 Sept 2023 End Date 11 Sept 2023
Working Hours 08:00 – 17:00
Precise location(s) of activities:
ACC E-House
Description of activities:
Visual check of FCP, it was reported from Tyco B6 that the FA signals is not responding.

Select and Provide Ref # of any applicable certificates/checklists:

Excavation Confined space Working at height Hot Works Radiography
Created Opening Pressure Testing Site Road Closure Certificate Night Shift Checklist
PART 2 – Precautions
Limitation of work/work area to achieve safety from the system:

Revalidation
DATE CP NAME CP SIGN SAP NAME SAP SIGN
DAY 2
DAY 3
DAY 4
DAY 5
DAY 6
DAY 7
PART 3 – Issue
Senior Authorised Person (Work Area / System Access) – I certify that access for work is granted for the work area /
system stated in Part 1.
Name: Time:
Signature: Date :
Senior Authorised Person (Work Activity Performance) – Permission is granted to undertake the work described above
using the agreed precautions in Part 2.
Name: Time:
Signature: Date :
LOTO Co-ordinator - I have reviewed the task co-ordination and authorise for the task to proceed.
Name: Time :
Signature: Date :
Received by Competent person - I accept responsibility for carrying out the work in accordance with this Limited works
certificate and no other work will be done by me or the persons under my control at the above location.
Name: Time:
Signature: Date :
PART 4 – Clearance
Cleared by Competent person - The activities authorised by this document have finished and all personnel working under
my control have been withdrawn from the work area. And any barriers have been replaced and secured
Name: Time:
Signature: Date :
Cancelled by Senior Authorised Person - The activities authorised by this permit have now ceased.
Name: Time:
Signature: Date :
Cancelled by LOTO Co-ordinator – The activities authorised by this permit have ceased and the permit is closed.
Name: Time :
Signature: Date :