HYPERSCALE DATA CENTER

GIIC Block BB No. 2B Jl. Tol Jakarta - Cikampek Km. 37, Cikarang Pusat

PERMIT TO WORK
Document Number : . . . /TDE/HDC/G-PTW/X/2022 Issue Date Format : 7/10/2023 Revision : - Page : 1 of 1

1. T Y P E O F W O R K (select one work item, more than one job then make another permit)

[ ] Energy Isolation [ ] Lifting Operations [ ] Temperrature Extremes

[ ] Electrical [ ] Mobile Equipment [ ] Noise
[ ] Ground Disturbance [ ] Confined Spaces √ Other : Penarikan Kabel Optik
[ ] Driving & Off-Road Vehicles [ ] Hazardous Materials (+ Hot Work) [ ] Other :
[ ] Working from Heights [ ] Material Handling [ ] Other :
2. I N F O R M A T I O N O F W O R K
1. Company : PT. FAJARMITRA

2. Date of Application : 08 Juli 2023

3. Nature / Details of Work : Penarikan kabel

4. Location of Work : Kampus HDC Details Location : 1. Mainhole, 2. Ruang Interconecting A dan B :

5. Work Supervisor Incharge : Darwin Siregar, Contact Number : 081316151677 :

6. OHS Supervisor : Rudi Contact Number : 0811211232 :

7. The Number of Workers : 7 Manpower

Work Start Date : 10 Juli 2023 : Work Start Time : 08.00 : WIB
8. Duration of Work :
Work Completion Date : 18 Juli 2023 : Work Completion Time : 17.00 : WIB

3. H A Z A R D S I D E N T I F Y B Y A P P L I C A N T
[ ] Liquid or Gas Under Pressure [ ] Lifting operation [ ] Slip / Trip / Fall

[ ] Flammable Material [ ] Shut Down Hazard [ ] Confined Space

[ ] Flying Article / Spark [ ] Toxic Material [ ] Access to Work Position

[ ] Naked Flame or Arc [ ] Live Work [ ] Drop Object

[ ] Electricity [ ] Explosive Material [ ] Beside Water

[ ] Moving Machinery / Vehicle [ ] Depressurized [ ] Other :

4. P R E C A U T I O N S T O B E T A K E N B Y A P P L I C A N T
[ ] Gas Testing Required [ ] Air/ Gas Line Connection Pinned/ Secured [ ] Turn Off Unused Equipment

[ ] Provided Ventilation Fan [ ] Area Free of Flamable Materials [ ] Electric Equipment Properly Connected

[ ] Consider Adjacent Works [ ] Provided with Suitable Access and Egress [ ] Fire Watcher / Hole Watcher

[ ] Barricade Required [ ] Equipment Checked Before Starting [ ] LOTO System

[ ] Fire Exthinguisher in Place [ ] Sufficient illumination [ ] Other :

5. P P E & S A F E T Y E Q U I P M E N T R E Q U I R E D
√ Safety Helmet [ ] Cotton Gloves [ ] Breathing Apparatus

[ ] Safety Glasses [ ] Rubber Gloves [ ] Full Body Harness / Fall Arrest System

[ ] Masker [ ] Welding Gloves [ ] Life Line

√ Safety Vest [ ] Ear Plug / Muff [ ] Other :

√ Safety Shoes [ ] Face Shield / Welding Mask [ ] Other :

6. W O R K P E R M I T A T T A C H M E N T
[ ] Methode of Prosedur [ ] Job Safety Environment Analysis [ ] Other :

7. V E R I F I C A T I O N
Proposed By
Acknowledge By Approved by
Applicant By Verified By Approved by
PT. FAJARMITRA PT (Contractor) PT (Contractor) PT Telkom Data Ekosistem PT Telkom Data Ekosistem

DARWIN SIREGAR Rudi BERNARD SIHOMBBING (Nama HSE) (Nama Operation Manager)
(Supervisor) OHS Project Mmanager (Jabatan) (Jabatan)

WORK PERMIT DAILY CHECK

Close Permit by
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
TDE
Date

Work Leader

SM Contractor