HEAVY EQUIPMENT PERMIT

at your side REOUIREMENT

PTW No.:. _ _ _ _ __

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Project Description:
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Time Start: _ _ _ _ _ _ _ __
Contractor Project In-Charge:---------
BIPH Project In-Charge: _ _ _ _ _ _ __
Heavy Equipment Operator's Name and Signature: l'\lf/508/l He;e/?'O/!/iJVT 0{1)(0/o/ltft- P,k;l}/}05 CZJ Location of w o r k : - - - - - - - - - -

Type)>f Heavy Equipment Works

~eavy Lifting Works D Heavy Equipment Works for Construction
Heavy Equipment to be used: Judgment:
Heavy Equipment to be used: Judgment:

~
o ift, capacity:_ __ _ ( Please attached certificate of inspection) D Passed D Failed
D Dump Truck (Please attached inspection certificate) 0Passed D Failed
D rane, capacity: _ ___( Please attached certificate of inspection) 0Passed D Failed
D Back Hoe (Please attached inspection certificate) 0Passed 0Failed
Boom Truck, capacity:___{ Please attached certificate of inspection) 0Passed D Failed
D Bull dozer (Please attached inspection certificate) D Passed D Failed
D Equipment Certrricate Inspection {attach certificate)
D Cement mixer{Note: shall have no exposed moving chains and gears)
Other Lifting Equipment:
D Man Lift (Please attached inspection certificate) D Passed D Failed
Ochain Block, capactty:____(Please attached load test certificate)
0Jack Lift, capacity: {Please attached load test certificate) D Others : _ __ _ _ _ _ _ _ __
D Rollers, capacity: (Please attached load test certificate)
(Please attached inspection certificate (if applicable))0Passed 0Failed
0TjPimfcfRiggerman (Pis. attach certificate)
D Equipment Operator Certification {Pis. attach TESDA NCll certificate)
c:aEquipment Operator Certificate {Pis. attach certificate)
D Warning Signs
Oweather Condition: (Stop work during rainy and strong windy days)
D Barricade
Dwaming Signs
Owatchman I spotter/ traffic man:._ _ _ _ __ _ __ _ _ __ _ _
QKe of tag line 0Hardhat
EJBarricadefor swing clearance and parking area
Load to be lifted: CnOI 5t7 _k
Quantity: LJ Weight: ~- -0-
eJ{;''f({(fl[ D Traffic vest
D Traffic gloves I flag
Owhistle
0uttlng and transport plan
(Pis. attached execution plan, area layout and route affected by the activity.)
Other Precautions
lifting Area Inspection:
D Area for lifting and transfer path been cleared for obstruct ion and
properly prepared.
Outting zone has been barricaded to prevent access by unauthorized
personnel.
Dcheck integrity of the ground (trenches and manholes below) of the
lifting area and transfer path. Provide additional supports if needed.

Prior to use on site, check for the following: (Nore: To be check by BIPH Safety Officer)
Checkttems Good Need Repai' N/A ESH Judgment
Tires
D D D
Sea t belt
D D D D Fit to opera te.
Side mirrors D D D Remark:
Horn and ga uges D D D
Lights (head ligh~ backlight, brake light and strobe light) D D D
Turn signals D D D
Backing alarms D D D
Bra ke condition D D D
Fire exti ngu isher condition D D D
Engine oil D D D D unfit to operate.
Rigging s\ings condition D D D Rema rk ::
Blade/Boom/ Ripper condition D D D
Ground engagi ng attachment D D D
Frame, ladder{s), and walkway D D D
Hand grabs and steps D D D
Power cable I hoist cable/ cha in s D D D
Steeri ng wheel condition D D D
Outrigger jacks/mat D D D

Other safety insp«tion items: Yes No

1. Presence of any overhead obstructions su ch as electrical wires, trees e tc.? D D
2. Presence of groun d support to maintain the integrity of the ground? D D
Environmental che-ck items:
1. D D
2. D D
Conformed by: Approved by:

Contractor Project In.Ch arge BIPH Safety O fficer

(Signature over Printed Name) (Signature over Printed Na me}

REC0102-ESH212
RevOl