PERMIT TO WORK

Permit No.

SECTION I
Apply for activity: Location :
Contractor : Trade :
Standing Supervisor: H/P No.:
The permit is request from : (Date) On : am/pm
The permit is valid until : (Date) On : am/pm
Description of Work:

SECTION II
A Safe Operating Procedure/ HIRARC has been provided and clearly train to workers in TBM before works
YES NO

SECTION III
SAFETY PRECAUTIONS TO BE CARRIED OUT : (Circle one and initial) To be filled up by the
Site Supervisor together with Approver:
No Description Observation Initial
1 Has survey been carried out to confirm underground utility services Yes/No
2 Has Risk Assessment been carried out to identify potential hazards, risks and
Yes/No
control measures
3 Has the Competent Engineer produced the ground stability calculation Yes/No/NA
4 Work area is barricaded and warning signs displayed Yes/No
5 The barricading tape is reflective and illuminated at night Yes/No
6 Have all the excavation area been installed with Toe-Board to prevent falling object i Yes/No/NA
7 Has the excavation been battered or benched or shored Yes/No
8 Safe access and egress from and to the excavation is provided Yes/No
9 All heavy equipment and vehicles are kept 2 meters away from the excavation Yes/No
10 All workers are wearing Helmet and Safety shoes Yes/No
11 Have all the workers been Safety Inducted and has Site Pass Yes/No
12 Have all the workers involved been trained in Excavation Hazards and Controls Yes/No

Other Precautions:

SECTION IV
PTW Request by (contractor supervisor / SSS) Job Cancellation :PTW Cancellation / Failed (SHO)
I hereby agree to be supervise and responsible for this activity and I have checked and confirmed this PTW application is failed /
will make sure my team members comply to the requirements stated cancelled. This permit is now cancelled.
in this permit.
Sign: Sign:

Name:
Name:
Date: Time :
Date: Time :

Issuance Approval : Recommended Approval (SHO) Issuance Approval : Approval and Authorization (PM)
I recommended the approval of the work operation and executed
I hereby approve the work operation to be executed safely.
safely.
Sign:
Sign:

Name:
Name:
Date: Time :
Date: Time :

SECTION V
Job Completion
The job has been completed. Housekeeping has been carried out and original condition has been restored.

Sign:

Name:
Date: Time :