WORK PERMIT

This permit must be displayed prominently at the area where the work is to be carried out and protected from being
damaged. Damaged permit shall be considered as invalid.

Work Information: Permit Number WP

Project / Work area : BLR Renovation Project
Company Name : PT. MKK BLR-MKK-WP01-WPE-ST-01-00-001-01
Contractor Supervisor : Wira Hadi Kusuma
Starting Date / Time : 24-06-2022
Completion Date / Time : 12-07-2022
Job Description :Pekerjaan Bongkaran / Demolish Area All Day Dining

Systems Affected:

Any Utility System / Piping Electrical System Fire Protection System

Tele-Communication Data-Communication System Roof Systems
Parking Lot Road Closure
Others _____________________________________________________________________________

Name Supervisor Safety officer

1. Wira Hadi Kusuma 2. Arie Prima

Personal Protective Equipment (PPE)

Hard Hat Safety Shoes Safety harness Dust mask
Eye protection Gloves Hearing Protection

Others : Safety Vest

To Be Completed by Site Work Engineer:

Length of Excavation: (___m) Depth of Excavation: (_____m)
List nearby Facilities/Hold Points:

Associated Permits and Safety Requirements

Site As-Built Drawing must be attached for each excavation
Drawing Reference No.:___________________________

Tools to be used:
Hand Tools Excavator Bulldozer Vibrator Elec Tools Compressor

Others: Jack Hammer

Safety Requirements and Protective Equipment to be Used

(To be Completed by Authorized Task Supervisor and verified by Authorized HSE Engineer)

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Hazards identified
Overhead power line Underground facilities is hidden Overloading equipment
Collapse Deep excavation (>2m) Unknown ground condition
Soft/wet ground Water accumulation Limit of access
Bad weather affected Moving machinery Night shift
Others:_____________________________________________________________________________________

Precautions to be taken
Before Starting
Drawings, Method statement has been approved Area to be provided with suitable access and egress
Barriers/signs to be in place Underground survey for un-identified objects in place
Machine guarding and Tool Box Talks took place

During Work
Barriers and signs isolate area
Traffic control procedure in place
Banksman is provided at all time
Stop work in unexpected condition found
Suitable PPEs for all personnel
Safe load working for all equipment to be followed
Method statement strictly followed
Soil survey and slope checked by competent person

After Work
The trench area to be left in clean and secure conditions Plant, equipment to be removed to safe area.

Applied Soil Protection:

Slope Shoring Stepping/Benching Trench Box Sheet Pile

Others:_________________________________________________________________________________

PERMIT AUTHORIZATION
I certify that all actions and conditions necessary for safe work have been performed.

Name: Wira Hadi Kusuma Signature: ___________________ Company: PT. MKK

Date: 14 / Juni /2022 Time: 14 : 00

Name: ______________________ Signature: ___________________ Company: ARCHETYPE CSA/MEP

Date: / /20 Time: ___________

Name: ______________________ Signature: ___________________ Company: ARCHETYPE HSE

Date: / /20 Time: ___________

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 Assessment & inspection review by OHSE:
Assessment is based on compliance to safe work procedures, tools conditions, area demarcation, warning signage,
PPE compliance, housekeeping and worker behavior.

Date /Time Remarks Signature

PERMIT WORK COMPLETED and Inspection of Work Completed

Post Inspection

Work Area is handed over to: _____________________________________________

Fire watch Inspection has been completed by: __________________________ Date / Time; _________________

Housekeeping has been completed and inspected by: __________________________

Contractor Supervisor: __________________ Date: ________________ Signature: __________

Documents returned to OHSE Office on Date: _____/_____/________ Time: _____:______

Archetype CSA/MEP: ___________________ Date: ________________ Signature: __________

Archetype HSE: _______________________ Date: ________________ Signature: __________

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Additional Remarks

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