SAFE SEAS SHIP MANAGEMENT FZE Issue Date: 25-Mar-22

Safety Management System Rev No: 0

Chapter 13 – Forms Checklist Rev Date: --
Revised by: DPA
PEM-9A Hot Work Permit Request Approved by: MD

Vessel: Date:

Loaded
Date/Time Job Vessel Condition:
Planned: Ballasted

Cargo
Aft Open Deck 0 Enclosed Space %%%EnclosedSpace:check%%%
✘
Engine Room %%%Box:Check%%%
✘
%%%Box3:Check Cargo Holds
Forward Open Deck ✘ %%%CargoHolds:check%%%
✘
Area: %%%
In Tank %%%InTanks:check%%%
✘
On Pipelines %%%Box1:Check%%%
✘ On or Near Tank Deck %%%Box4:Check%%%
✘
In Pump-Room %%%InPump:check%%%
✘

Exact Location:

Work Scope:

Reason Necessary:

Planned Safety Precautions: (Including Tank

Preparation)

Master's Name:

For Office Response:

Comments from Marine or HSQE

Department:

Name:

Signature

Comments & Approval from Technical

Department:

Name:

Signature
%% %%
Permitted: Yes %yES:Chec
✘
No ✘
%No:Chec Reason If denied
k%%% k%%%

File: Office/Ship Frequency: Monthly Page1 of 1