Permit to Work Form C (R1)

DATE: 05/12/2023 LOT/TENANT: LAC

APPLICANT: AMMAR NAME OF CONTRACTOR: SHENKO INTERIOR DESIGN SDN BHD
CONTACT NUMBER: 019-510-7985 CONTRACTOR CONTACT NO: 017-372 5231
WORK DETAILS:
TYPE OF WORK: PROPOSED DURATION OF WORK:
Renovation Stock take Flyer distribution
Reinstatement Grease trap Event set up DATE: 10/12/2023 to 12/12/2023
New Construction Servicing Event dismantles 6.00AM
Minor touch up Cleaning Kiosk set up TIME: 10.00PM to
Fit out works Inspection Kiosk dismantles
Painting Pest Control Event/Promotion LOCATION OF WORK:
Electrical/lighting Furniture & fittings Others
Plumbing Maintenance LAC LOT LG-04

DETAIL/DESCRIPTION OF WORK:
SUPERVISOR NAME: David Foo
Changing of Signage I/C OR PASSPORT NO: 760109-14-5361
CONTACT NUMBER: 017-372 5231

WORKER DETAILS:
*Only those in the list shall be issued with worker pass
NO. WORKER NAME I/C OR PASSPORT NO. REMINDER:
1 Refer to the name list attachment All workers are compulsory to
attend Safety Induction before
2 commencement of work. Kindly
arrange your staff/workers to sit for
3 safety induction early before
4 applying the work permit. Safety
induction only valid for 6 months.
5
* Please attached additional name list (if any) together with this form.
*All documents are under Personal Data Protection Act (PDPA).

SIGN BY TENANT / APPLICANT WITH COMPANY STAMP: STAMP DATE & RECEIVED BY:

* I have read, understand & agreeable all the regulations and Penalty may be impose as stated in * For Fit Out Department Use Only
House Rules NU Sentral / NU Empire and the Terms & Conditions as statedin this form.

FOR OFFICE USE:

REMARKS:

VERIFIED BY: APPROVED BY:

................................................ …………………………………..
NAME: NAME:
DEPARTMENT: DEPARTMENT:
DATE: DATE:

*Please refer at the back for terms & conditions.

 TERMS & CONDITIONS:
1. All contractor/tenant must apply Permit to Work (PTW) at management office.
Documents need to be submitted along with PTW are:
a) Workers name list.
b) Copy of N.R.I.C ONLY (local worker).
c) Copy of passport and visa work permit ONLY (Foreign worker).
d) Copy of Certificate of Competent person (if required).
e) Method of Statement (if required)
f) List of Equipment (if required)
g) Copy of Form G, H & Q (new tenant set up).
h) Company of insurance RM 2 million for public liability & worker (if required).
i) Working schedule (if required).
j) Contractor/Tenant must attend Safety Briefing (if required).
k) RM 10.00 will be charged for each working pass for construction work (if required).

2. Please attach detail and photographs of all item for any removal of assets.
3. All attachment submitted along with PTW must be endorse with Company rubber stamp.
4. All PTW or Hot Work Permit application must be applied at least 3 working days prior to commencement of work.
5. This form must be submitted in hard copy to management office level 1, NU Sentral.
6. Time for PTW submission is from 9 am – 5 pm ONLY. Any submission after 5pm will be consider as next day submission.
7. The PTW and Safety pledge needs to be posted/display on the hoarding during work at site.
8. Hot work/Hacking/Drilling/Cutting can only be carried out after 12.30am.
9. Any works that create noise/odour is strictly prohibited during Shopping Centre business hours.
10. If any HOT WORK involved at the site, contractor/tenant are required to submit Hot Work Permit application form.
11. All urgent repairing work after 10pm shall be undertaken by our in-house contractor and will be back charged to respective
tenant.
12. Protections on shop-front & back corridor of landlord common flooring is required before commencement of work.
13. All workers are compulsory to wear the inhouse safety vest.
14. Clean up work is required before leaving the work site.
15. Collect & Return work pass at check point counter at loading bay before & after work completion.
16. The management reserve the right to stop all work once received any complaints or other disturbance circumstances.
17. The management reserve to impose penalty on any Non-Compliance/Violation/Negligence of terms and conditions.
18. In the event there is an error or forgery on the documents submitted by the contractor/tenant for this application, the Landlord
and NU Sentral Management shall not be held liable for; and the contractor/tenant shall indemnify the Landlord and NU Sentral
Management against all losses and damages suffered and/or incurred by the Landlord and NU Sentral Management arising out
of such error or forgery.
SAFETY REGULATIONS:
1. Illegal foreign workers are strictly not allowed as stated in section (3) of the immigration act 1959/63 (Act 155)
2. All workers are required to wear a proper Safety Attire while work at site.
3. Eating and smoking is not allowed in any part of the demised premises.
4. All approved workers shall work within the demised premises except where use of external facilities is necessary, or unless
otherwise approved. No work should be carried out in the common area.
5. The contractor’s/tenant will be held responsibility for the damage of any nature caused by them or related workers to any part
or item on common area, exterior paved and joining premises.
6. Those who NOT listed in name list are declined to enter the mall/premises.
7. All workers must wear safety shoes, long pant and comply with safety regulations.
8. All incidents must be report immediately to Security Department.
9. The management has the right to issue a Stop Work Order to the contractor due to breach of contractor house rule &
regulation/safety pledge, unsafe act, unsafe conditions or other circumstances which may cause hazard.
10. All workers must attend Safety induction/briefing organized by safety in charge.

PENALTY:
1. Loss of any Pass- RM20
2. Loss or broken of safety vest- RM100
3. Failure to maintain cleanliness of the premises including the shop front and back of house-RM 500.00 + service cost
4. Failure to comply with Permit to Work (PTW) & Hot Work Permit terms & conditions-RM 1,000.00
5. Causing any unpleasant odour or loud noise during business hour-RM 500.00
6. Failure to comply with safety and health act 1994-RM 10,000.00
7. Not wearing appropriate Personal Protective Equipment (PPE)- RM100.00
8. Fighting or performing any illegal activities within work site- RM1,000.00
9. Tapping of electricity and water without management approval-RM 5,000.00
10. Smoking in non-smoking area- RM 1,000.00
11. Obstruction to building emergency walkway and back room area-RM1,000.00
12. Damage to landlord provision during fit out period/move out period-RM 5,000.00 + repair cost

For any enquiry please contact management office at 03-22766149

 INDEMNITY FORM

To: NU SENTRAL SDN. BHD. (REGISTRATION NO.: 200601034269 (754028-P))

Level 9, Block D, Dataran PHB,
Saujana Resort, Section U2,
40150 Shah Alam,
Selangor Darul Ehsan

(hereinafter referred to as the “Landlord”)

ZM PROPERTY MANAGEMENT SDN. BHD. (REGISTRATION NO.: 201501043846 (1169167-P)

Level 33A, Menara NU 2,
No. 203, Jalan Tun Sambanthan,
Kuala Lumpur Sentral,
50470 Kuala Lumpur,
Wilayah Persekutuan Kuala Lumpur

(hereinafter referred to as the “Property Manager”)

(1) LAC Global Brands (M) Sdn.Bhd

We, ………………………………………………………………………………………. (insert company name / full
545007-W
name) (Registration No.: ……………………………………………………….) (insert company’s registration
200101009251 NO.8 Jalan 6/91,Taman Shamelin Perkasa
number / identification number) of …………………………………………………………………………………………
…………………………………………………………………………………………………………………
Batu 3 1/2, Jalan Cheras 56100 KL.Malaysia (insert full address)
hereby undertake to indemnify and keep indemnified the Landlord and Property Manager
from and against all damage, losses, costs and expenses suffered by us, our employees,
contractors, agents, servants and properties in relation to the installation, set-up, storage or
dismantling of any equipment, apparatus, devices, materials, appliances or other facilities in
connection with the services, operations, performance of the works, business, trade,
promotion and exhibition (hereinafter referred to as the “Activities”) conducted by us as NU
Sentral Shopping Centre (hereinafter referred to as the “NU Sentral”).

(2) We further undertake to indemnify and keep indemnified the Landlord and Property Manager
from and against all actions, claims, demands, damage, losses, costs and expenses including
damages caused to NU Sentral or any part of NU Sentral or to any adjacent or neighbouring
properties or to any person, which the Landlord and Property Manager shall or may be or
become liable as a consequence of the Activities or of any our acts, omission or negligence,
our employees, contractors, agents and servants.

……………………………………………………..
(Authorized signatory)
Name : Ammar Mashhor
Designation : Operations Dept
Date : 05.12.2023
Company Stamp :
 PERAKUAN PENDAFTARAN
Adalah dengan ini diperakui bahawa kontraktor yang dinyatakan di bawah ini telah berdaftar dengan
Lembaga mengikut Bahagian VI Akta Lembaga Pembangunan Industri Pembinaan Malaysia 1994.
Pendaftaran ini adalah tertakluk kepada syarat-syarat yang telah ditetapkan bersama perakuan ini.

No. Pendaftaran : 0120170106-WP183633

Nama Kontraktor : SHENKO INTERIOR DESIGN SDN. BHD.

Alamat Berdaftar : NO. 38, LORONG YAP HIN OFF JALAN PASAR
55100 KUALA LUMPUR
WILAYAH PERSEKUTUAN KUALA LUMPUR

Daerah : KUALA LUMPUR

Tarikh Mula Berdaftar : 06/01/2017

GRED KATEGORI PENGKHUSUSAN

G5 B B04
G5 CE CE21
G5 ME M15

Tarikh Mula Berkuatkuasa : 28/12/2021

Tarikh Habis Tempoh Perakuan : 27/01/2025

STATUS: AKTIF

Ketua Eksekutif
Lembaga Pembangunan Industri Pembinaan Malaysia
Tarikh: 28/12/2021
 SYARAT-SYARAT PENDAFTARAN
1.Syarat Am
a) Perakuan ini tidak boleh dipindah milik.
b) Lembaga mempunyai hak mengkaji semula gred
pendaftaran kontraktor dari semasa ke semasa.
2.Tanggungjawab dan Obligasi Kontraktor
a) Kontraktor hendaklah mematuhi peruntukan-peruntukan
Akta Lembaga Pembangunan Industri Pembinaan
Malaysia 1994 ('Akta'), peraturan-peraturan yang dibuat
di bawahnya dan apa-apa terma, syarat-syarat atau
sekatan yang dikenakan oleh Lembaga dari semasa ke
semasa.
b) Kontraktor tidaklah boleh menyertai mana-mana tender
atau melaksanakan apa-apa kerja pembinaan selepas
habis tempoh Perakuan ini dan sehingga ianya
diperbaharui.
c) Kontraktor tidaklah boleh mengakujanji membina apa-
apa projek pembinaan yang melebihi nilai kerja
pembinaan yang dinyatakan di bawah gred pendaftaran
dan tidaklah boleh melaksanakan apa-apa projek
pembinaan di luar kategori pendaftarannya.
d) Kontraktor hendaklah mengemukakan maklumat
mengenai apa-apa kerja pembinaan atau kontrak dalam
tempoh empat belas hari selepas diaward atau sebelum
mula kerja atau mana-mana terdahulu.
e) Kontraktor hendaklah mengemukakan apa-apa
maklumat yang dikehendaki oleh Lembaga dari semasa
ke semasa.
f) Kontraktor hendaklah mempamerkan Perakuan
Pendaftarannya yang dikeluarkan oleh Lembaga atau
salinan Perakuan Pendaftaran yang diperakui oleh
Lembaga di tempat perniagaannya.
g) Kontraktor hendaklah mempamerkan nombor
pendaftaran atas papan tanda di setiap tapak
pembinaannya.
h) Kontraktor hendaklah memohon untuk memperbaharui
pendaftaran dalam tempoh enam puluh hari sebelum
tarikh habis tempoh yang dinyatakan dalam Perakuan
itu.
i) Kontraktor hendaklah mematuhi semua kehendak dan
ketetapan di dalam Kod Etika Kontraktor.
j) Kontraktor hendaklah melantik pekerja binaan mahir
dan penyelia tapak yang diakreditasi dan diperakui oleh
Lembaga.
k) Semua pekerja di tapak bina hendaklah mempunyai Kad
Personel Binaan yang masih sah.
3.Tindakan Tatatertib
Pendaftaran kontraktor hendaklah dibatal atau digantung jika:-
a) kontraktor tidak mematuhi kehendak mana-mana
undang bertulis yang lain;
b) kontraktor telah dihukum menjadi bankrap;
c) petisyen penggulungan berhubungan dengan kontraktor
telah diserahkan;
d) kontraktor melanggar atau tidak mematuhi mana-mana
peruntukan Akta;
e) kontraktor telah mendapat Perakuan dengan membuat
atau menyebabkan dibuat apa-apa akuan, pemerakuan
atau representasi palsu atau fraud secara bertulis atau
selainnya;
f) kontraktor meninggalkan apa-apa kerja pembinaan yang
diakujanji tanpa apa-apa sebab yang munasabah;
g) kontraktor telah didapati bersalah kerana cuai oleh
mahkamah atau mana-mana lembaga penyiasatan yang
ditubuhkan di bawah mana-mana undang-undang
bertulis berhubungan dengan apa-apa kerja pembinaan
yang diakujanji; atau
h) kontraktor telah melanggar mana-mana terma dan
syarat-syarat Tanggungjawab dan Obligasi Kontraktor
yang dinyatakan dalam perenggan 2.
a.Jadual Gred & Had Tender
Gred Keupayaan Menender / Menjalankan Kerja (RM)
G7 Tiada Had
G6 Tidak melebihi 10 juta
G5 Tidak melebihi 5 juta
G4 Tidak melebihi 3 juta
G3 Tidak melebihi 1 juta
G2 Tidak melebihi 5 ratus ribu
G1 Tidak melebihi 2 ratus ribu
4.Definisi Status
a) Baru: Kontraktor yang baru berdaftar
b) Aktif: Kontraktor tempatan yang di anugerah projek
dalam tempoh tiga (3) tahun terkini atau mempunyai
projek sepanjang tempoh pendaftaran berkuatkuasa.
c) Dorman: Kontraktor yang tidak di anugerah sebarang
projek dalam tempoh tiga (3) tahun terkini.
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To whom it may concern,

RE: Shenko Worker's Name List

Location: LAC - Change Signage

No. LORRY NUMBER

1. VKS 9110
2. WA 7716 J
3. VJP 540

Please find below for our worker's name list for your further action :-

No. NAME NRIC No:

1 Foo Chee Han 760109-14-5361
2 Wong Wai Luen 760611-14-5885
3 Muhamad Amirul Bin Shamsuddin 921004-10-5499
4 Siva A/L Balras 750705-08-6397
5 Lee Kin Wai 630228-10-7805
6 Leong Shi Jie 951127-01-6231
CARPENTY
7 Ng Kuen Seng 820106-14-5755
8 MD Arshad EH0220193
9 Mohammad Abdullah EJ0078640
10 MD Zahurul Islam EJ0601874
11 Chen Wai Yin 780610-08-5647
12 Ripon EL0076197
13 Ong Chin Poh 781121-10-5461
14 Gooh Wai Lung 871231-05-5345
15 Tan Yen Sing 820916-10-5165
16 Mohammad Rasel Molla EG0449631
17 Saurav Hasan Sujan EG0246591
18 Kamrul Islam EE0314964
19 Md Nazrul Islam EK0236412
20 Mozibar BY0782326
21 Md Faaruk EK0234701
22 Md Lablu Mir B00684321
23 Mostafizur Rahman EF0324295
24 Nazmul EG0585230
25 Md Shamim Hossain B00398619
26 Md Sah Alam EK0306655
No. NAME NRIC No:
27 Mohammad Rubal A03053278
ELECTRICIAN
28 Ng Soon Choy 711009-10-5329
29 Ng Soon Heng 730913-14-5277

Your arrangement is much appreciated.

Should your have any queries please do not hesitate to contact the undersigned.

Yours Sincerely,

SHENKO INTERIOR DESIGN SDN BHD

David Foo
David Foo
General Manager