GS Engineering & Construction Corp.

Permit To Work Permit No :

GS-AMBSD-SF-IR-13-001

Work Activity:
Working at Height
A. Application (By Contractors/subcontractors Nominated Person)
Requesting Request By: Date:
Company:

Plant Area: Description of Work: (attach drawing/sketch as necessary)

Time Date Time Date

Permit is required from To
(1 Week) :

B. Precautions to be taken prior to commencement and during the work (by Nominated or Competent Person)
A risk assessment and/or a method statement shall be attached to the Permit to Work request.
Yes No Other Control Measures
Full Body Harness
Safety Line
Scaffolding
Ladder
Adequate Lighting
Fall Protection
Warning Sign Location
Tag in Place
Handrail
Safety Net
Other
C. Prepared (to be completed by Subcontractor’s Nominated person)
I certify that have read and understood this permit and that the work will be earned out In accordance with its requirements.
Signed Date:

D. GS E&C – Health Safety Environment Manager

Permission is given for the work to proceed subject to the conditions specified above:
Signed Date:

E. GS E&C - Construction Manager

Signed Date:

F. GS E&C – Project Manager

Signed Date: