Project No.

P-OkiPL1
OKI PULP & PAPER MILL PROJECT
Document No. P-OkiPL1-100-15-FRM-000
[ FORM - OKIPL1] Revision 01
LIFFTING WORK PERMIT Page 1 of 2
In case of emergency the permit will be considered invalid.
Issue Date 20-Oct-16
Permit No.: OKIP2/H&S/PTW/2023/_______ General Permit Reference No.
A Time Schedule
Start Date: Finish Date:
From (hh:mm):
≤ Non-working day ≤ Day shift ≤ Night shift
Company Name : Permit Holder Name:
B Location And Activities
Work Areas / Components of plant:

Liffting

Activities to be executed: 1 5
(to complete work) 2 6
3 7
4 8
C Measure
C1 Safety Controls as defined in (all documents MUST be attached to the work permit):
Yes No

≤ Job Safety Analysis (Name, doc.no., revision, date)

≤ Liffting study (Name, doc.no., revision, date)
≤ Other (Name, doc.no., revision, date)
C2 Documents to be checked - Prior commence of work Comments & Definitions
Name
≤ Crane driver certified :
Driving Licence
≤ Crane certificate : Certificate Validity
Insurance No.
≤ Crane insurance :
Validity
≤ Lifting tools & tackles : Certificate Validity
≤ Daily checklist : Inspected By

C3 Additional Safety Controls - During work

≤ Lifting plan calculation
≤ Crane pad / Out rigger based plate
≤ Barricade and safetysign
≤ Rigger and Signalman
≤ Tag line

C4. Additional Safety Controls - Emergency Rescue Plan

1. PIC
Emergency Contact Number 2. Shift Leader
3. Health & Safety
C5. Additional Safety Controls - After work
1.
2.
3.
 Project No. P-OkiPL1
OKI PULP & PAPER MILL PROJECT
Document No. P-OkiPL1-100-15-FRM-000
[ FORM - OKIPL1] Revision 0
LIFFTING WORK PERMIT Page 2 of 2
In case of emergency the permit will be considered invalid.
Issue Date 30-Jun-15
D. List of authorised personnel (if special education/training or further personal prerequisites are required)
Name / Badge-ID or similar
1. 5.
2. 6.
3. 7.
4. 8.
E. Work authorisation following an inspection of the work site before commence of work
1. Permit has been reviewed and accepted by PT. OKI HSE Department

Date Name Signature

2. Permit has been reviewed and accepted by COMPANY (Permit Endorser)

Date Name Signature

3. Definition of safety precautions and work permit by COMPANY (Permit Issuer)

Date Name Signature

4. Defined safety precautions agreed and accepted by CONTRACTOR (Permit Holder)

Date Name Signature

F. Daily confirmation that the conditions are unchanged and controls are still in place following an inspection of the work
site before commence of work
Date
1. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
2. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
3. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
4. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
5. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
6. workday :
Shift Leader Process Electrical Mechanical H&S PIC
Date
7. workday :
Shift Leader Process Electrical Mechanical H&S PIC
G. Notice of completion of work and closure of work permits

Date Shift Leader Process Electrical Mechanical H&S PIC

H. Completion Inspection By
≤ Notified and accepted by PIC.
≤ Notified and accepted by Shift Leader.
≤ Notified and accepted by Process Dept.
≤ Notified and accepted by Electrical Dept.
≤ Notified and accepted by Mechanical Dept.
≤ Notified and accepted byHealth & Safety Dept.