VISTAMARINE SHIPBUILDING AND SHIPREPAIR INC

PERMIT TO WORK APPLICATION

Date Requested : __________________ Time in: ____________ Time Out: ________
Expected Date of Completion : _______________________________________
Nature of Work : ____ Electrical ____ Hot Work
____ Civil ____ Work in Confined Spaces
____ Mechanical ____ others, please specify
____ Working at Heights
Work Description : ______________________________________________________
______________________________________________________
Work Requested and Granted to : ______________________________________________________
Work Vessel : ______________________________________________________
Person/s to do work : (Use separate sheet)

BASIC SAFETY REQUIREMENTS PRIOR TO ACTUAL WORK

Requirements Safety Check
(For Contractor) (Safety Officer)
1. Area clear of combustible materials Yes No N/A Yes No N/A
2. Equipment completely isolated/de-energized Yes No N/A Yes No N/A
3. Area of equipment adequately lighted & ventilated Yes No N/A Yes No N/A
4. Area tested gas free & safe to work Yes No N/A Yes No N/A
5. Welding machine in good operating condition Yes No N/A Yes No N/A
6. Adequate entry & exit facilities Yes No N/A Yes No N/A
7. Warning signs in place Yes No N/A Yes No N/A
8. Source of power, water, etc., requested & provided Yes No N/A Yes No N/A
9. Firefighting facilities & equipment ready & manned Yes No N/A Yes No N/A

10. Gas Testing. Reading Air_______ Oxy_______ Other______________

SAFETY EQUIPMENT/GARMENTS REQUIRED ( )

1. Safety Shoes 6. Safety Harness/Life Line
2. Safety Helmet/Hard Hat 7. Safety Net
3. Gloves 8. Fire Extinguishers
4. Face Shields/Goggles 9. Others, please specify
5. SCBA

HAZARD IDENTIFICATION
List of Possible Hazard Action to be taken Status
(To be filled by the Contractor)
Fire explosion Maintain fire watch al the time Done
Slip trip and fall Good housekeeping For follow up
Inhalation of fumes Complete hotwork PPE Done
Working alone Buddy buddy system Done

Requested by, Indorsed by.

________________________ __________________________
Requesting Party Proj. Engr./Foreman

Checked and reviewed by, Approved by,

________________________ __________________________
Safety Officer ShipYard Superintendent
 We, the undersigned hereby acknowledged that all the hazards identified in this Risk Assessment had been
explained and clearly understood by each of us.

NO. Name Position Signature

1

9
10

Note: this permit can be terminated at any given time, if the safety condition within the specific plant areas
become too risky and that available PERSONAL SAFETY EQUIPMENT fails.