Doc.

No : FORM-03-OHSE-10

Hot Work Permit Revision : 01

SKDM Project 80 TPH Contractor: Permit No

In case of emergency the permit will be considered invalid.
A. Time Schedule
Start Date: Finish Date:
From (hh:mm): To (hh:mm):
B. Location Activity

C. Safety Controls (assess together between the permit issuer and the permit holder)
C1. Safety Controls as defined in (all documents MUST be attached to the work permit):
[ ] Job Safety Analysis (doc.no, revision, date):
[ ] Other (Name, doc.no., revision, date):
C2. Additional Safety Controls - Prior commence of work
[ ] Energy Isolation (electrical/ mechanical) Permit Ref. No :
[ ] Working at height: Permit Ref. No :
[ ] Confined space Permit Ref. No :
[ ] Assign fire watch Name:
[ ] Remove combustible and/or flammable materials
[ ] Cover remaining combustable and/or flammable materials/substances/liquids
[ ] Cover floor and wall openings (fire blankets)
[ ] Barricade work area (incl. lower levels)
[ ] Additional measures:
C3. Precautions to be taken: (Tick marks which are applicable)
Equipment & tools are inspected Additional PPE’s available (SCBA,FBH)
Working platform, Lifeline available Lighting system and access/egrees
Blower, exhaust available Is fire watch personnel is provided?
Area barricaded, Caution displayed Earthing properly done/Insulated welding cable used
Are suitable fire extinguishers, in no simultanious work nearest area
adequate numbers, kept ready for
firefighting? Specify the type : Gas test has been conducted and safe
Is the area clean and free of combustible/
flammable material
C4. Additional Safety Controls - After work
[ ] Inspection of work area after 30 min. after stopping the work
[ ] Others :
D. Personal Protective Equipment
[ ] Helmet [ ] Leather Gloves [ ] Ear Plug / Muffs [ ] Face Shield
[ ] Safety Shoes [ ] Safety Glasses [ ] Body Harness [ ] Cotton Gloves
[ ] Welding Cap [ ] Safety Goggles [ ] Face Mask Other
E. Work Authorisation (All signatures must be completed or else the permit is invalid)
Contractor Supervisor: (nama) Owner Supervisor:
Contractor OHSE: (nama) Owner OHSE:
Contractor Site Manager: (nama) Owner Construction Manager:
F. Nama Pekerja yang Bekerja di Lokasi Kerja Sesuai Ijin Kerja
1 4 7 10
2 5 8 11
3 6 9 12
G. Confirmation of work completion (Pekerjaan selesai, area dikembalikan ke kondisi awal & aman).
Contractor Supervisor: (nama) Owner Supervisor:
Contractor OHSE: (nama) Owner OHSE:
Contractor Site Manager: (nama) Owner Construction Manager:
Date/ Time :