HSE-PTW-001

WAWASAN CONSTRUCTION (M) SDN BHD

LIFTING ACTIVITY PERMIT TO WORK
SAFETY, HEALTH AND ENVIRONMENT DEPARTMENT
PERMIT NO. :
Valid for 7 days from the time of approval. Apply at least one day in advance. Work on Saturday, Sunday and Monday must be applied on Friday. All Lifting
Sketch(es) & lifting checklist MUST be attached
Application – To Be Completed By Work Supervisor / Engineer In Charge
Work Performed by Routine / Non-Routine
Name of Lifting Supervisor Contact Number
Name of Rigger Name of signalman
Name of Crane Operator PMA Number
Location
Date & Time of Work Date From To
Lifting Activity Checklist Item
Item Status Name Signature
1. Valid PMA, Lifting Gear and Operator Certificate
2. Pre-inspection of crane
3. Barricade & Warning Signage
4. Lifting Crew in Proper Attire
5. Safe Crane Access and Ground Condition
6. Outrigger Fully Extended on Steel Place / Wooden Block
7. Lifting Plan Available
HSE Assesses and Verified by:
Project Manager Verification and Approval:
Description of Work:

Permit Renewal (Date & Initial)

1 2 3 4 5 6 7
Applicant Spv.
HSE Supervisor
Checking, Evaluation, Assessment & Review of EHS Requirements by Site Supervisor
Work personnel briefed on risk-impact assessment of the work scope Work area is safe. Environment aspects eliminated.
Reasonably practicable measures are/ will be taken to safeguard the safety and health of work personnel and preservation of the environment.

Site Supervisor Name & Sign: Date & Time

Final Review & Assessment of EHS Requirements (By WCSB HSE Personnel)
I have reviewed the risk assessment and EHS requirements for the work and instructed subcontractors to eliminate or critically reduce the risks and impacts. Work shall be
stopped if there is a change in work conditions

HSE Personnel Name & Sign: Date & Time

Approval – By WCSB Project Manager
I’m satisfied that all reasonably practicable measures are/ will be implemented and enforced, and the working personnel are informed of the safety hazards & environmental
impacts and protection counter measures to be taken. Subcontractors are instructed that any work not stated in the work description shall not proceed

Project Manager Name & Sign: Date & Time

Closure of Permit to Work by Work Supervisor & WCSB HSE Personnel
Work has completed Housekeeping has been done Area is safe for others

Site Supervisor Name & Sign: Date & Time

Work has completed Housekeeping has been done Area is safe for others

HSE Supervisor Name & Sign: Date & Time

THINK SAFETY, ACT SAFELY, BE SAFE

Note: Shaded area must be filled with / = OK/Good X = Not OK/Bad NA = Not Applicable

Original copy must be displayed at work location

Produced by Mr. Faiez