THAMRIN NINE DEVELOPMENT HWP- 0000
Ph1 GA T1 RP MN -
HOT WORK PERMIT Ph2 GA T2 RP TH MR
Ph3 GA T3 - - -
Date Prepared: Date Start :
Permit is only valid for one job or one equipment operation in one location/area and valid for one day work
Attention : (Construction/ Safety Manager) Job :
Work Time : Start : Until :
Subject : Work Location :
Requested by: (Main Contractor) Total Workers :
Description of Work:
Permit Application (Completed by Performing Authority)
Contractor / Subcontraktor who apply the Permit to Work Acknowledge by : (Project Manager)
Company Name : Sign:
Site Manager Name : Sign:
( )
Engineer Name : Sign:
Name/ Signature :
Supervisor Name : Sign:
Tools / Equipment used:
Item Description Qty Item Description Qty Item Description Qty
1 5 9
2 6 10
3 7 11
4 8 12
Inspection of Work Location (Conducted by Site Safety Coordinator/ Inspector Prior Work Start)
Inspection shall be marked by "OK" atau "NA" (not applicable) in the suitable columns
Item Description OK/NA Item Description OK/NA Item Description OK/NA
1 FIRE EXTINGUISHER 5 NO SMOKING 9 NO OVERLOAD SOCKETS
2 FIRE WATCHER 6 REFUELING ENGINE 10 WELL VENTILATED AREA
3 FIRE BLANKET 7 ANY OIL SPILLED 11 HOUSEKEEPING
4 NO FLAMMABLE MATERIAL 8 NO FRYED WIRING 12 PPE
Based on the inspection result, then recommend : (Tick in the box)
Work activity as above can be performed ( ): The job above is not approved/postponed, with the reason ( ) :
Site Safety Coordinator/ Inspector Notice : Safety Infringement Report :
Inspected by : (Site Safety Coordinator/ Inspector) Acknowledged by : (Safety Manager)
Signature Signature
Date/ Name Date/ Name
Cool Down Inspection (Conducted by Site Safety Coordinator/ Inspector After Permit Over)
Based on the inspection result, then recommend : (Tick in the box)
Work activity has been FINISHED/ STOPPED : Work Activity has not finished yet :
Date : Time : A new permit shall be applied for extending the PTW ( )
Incident Report Issued : ( ) Statement Letter is issued ( )
Statement Letter/ Safety Infringement Issued : ( )
Inspected by : (Site Safety Coordinator/ Inspector) Acknowledged by : (Safety Manager)
Signature Signature
Date/ Name Date/ Name
Performed by : (SM Contractor) Site Authority : (Safety/ PM Contractor) Area Authority (PGW Safety Manager)
Date/Name (__________________________) Date/ Name (_____________________________) Date/ Name (______________________)
Distribution:
Attachment:
Form No: HWP-CME 080515
Revision No.: R0
