BANYU URIP PROJECT
INFRASTRUCTURE FACILITIES EPC - 5
WORK PERMIT SYSTEM
Doc No. REV.
IDBC-RH-SPZZZ-C00008 0 Health Safety Environment Page 1 of 3
Date / Tanggal :
PERMIT TO WORK Facility / Fasilitas :
Surat Izin Kerja No. of Work Permit :
Hot Work Cold Work Energy Excavation Confined Critical Lift
Pekerjaan Pekerjaan Isolation Penggalian Space Pengangkatan
Panas Dingin Isolasi Bekerja Kritis
Energi Diruang
Terbatas
1. Description/location of job / Uraian / Lokasi Pekerjaan
............................................................................................................................. ..........................................................................................................
...................................................................................................................................................... .................................................................................
............................................................................................................................................................................... ........................................................
No. of Worker / 2. Validity of Work Permit / Masa berlaku
Jumlah Pekerja Izin kerja
Work Permit Applicant /
Date / Tanggal :
Pemohon
From …………….....Hrs To.......................... Hrs
Sign / Tanda tangan
Work Permit Holder /
Pemegang Izin Kerja
Authorized Person / Penanggung Jawab
Check if applicable and explain below
3. Isolations / Isolasi Electrical
Mechanical Jika ada mohon dijelaskan dibawah ini
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Time and date isolated / Isolated by / Diisolasi Oleh: Position / Jabatan :
Jam dan Tanggal Isolasi:
………………………… ………………………………….. …………………………
4. Work Permit Requirement JSA & Risk Assessment Drawing Activity Rigging Plan
/ Persyaratan Izin Kerja
Work Method As build Drawing Underground Composite
(Check the hazards and the required precautions / Beri tanda pada bahaya dan
5. Hazards pencegahannya)
Liquid/ gas under pressure / Cairan Gas Confined spaces / Didalam Weather / Cuaca Fire / Kebakaran
bertekanan Ruang Terbatas
Electricity/ Toxins / Keracunan
Explosion due to combustibles / Ledakan Danger of falling / Bahaya Kelistrikan
dari material yang mudah terbakar Jatuh Lifting Ops. /
Moving machinery / Corrosives / Korosi
3rd party operations (explain below) / Pengangkatan
Peralatan / Mesin yang Pinch points /
Aktifitas Kontraktor (Jelaskan dibawah) Terjepit Scaffolding /
bergerak
Noise / Kebisingan Perancah
Flying particles or sparks /
Partikel terbang/Percikan api
Other Hazards / Bahaya Lainnya
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Precautions:
Airline (cascade)
Water flushing
Supervision
Grounding
Fire Extinguishers / Inert purging Stand-by-man Ventilation PPE
APAR
Job Safety Analysis H2S Monitoring Safety harness SCBA Barriers
(JSA)
Other precautions / Pencegahan lainnya :
BANYU URIP PROJECT
INFRASTRUCTURE FACILITIES EPC - 5
WORK PERMIT SYSTEM
Doc No. REV.
IDBC-RH-SPZZZ-C00008 0 Health Safety Environment Page 2 of 3
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
6. Gas Testing / Pengetesan Gas
Oxygen / Oksigen H2S Flammable Gas / Gas mudah terbakar
Date Time Reading Date Time Reading Date Time Reading
Tanggal Jam Hasil Tanggal Jam Hasil Tanggal Jam Hasil
Gas Tester by / Pengetesan Gas dilakukan oleh :
Name / Nama : Sign / Tanda Tangan :
7. Work Permit Issued / Pengeluaran Surat Ijin Kerja 8. Authorization of Company (if required) / Penanggung Jawab
The details of the permit have been discussed with the Permit Perusahaan (Jika diperlukan)
Holder and those involved / Surat ijin ini telah dibahas secara
rinci oleh Pemegang Ijin dan pihak -pihak yang terkait. Name / Nama :
Authorized Person / Penanggung Jawab Sign / Tanda tangan:
9. Issue and Acceptance / Pengeluaran dan Penerimaan Izin Kerja 10. Job Hand Over / Pengalihan Pekerjaan
I have checked the worksite and the required precautions have Permit Holder changed at / Perubahan Pemegang Izin pada
been taken and discussed with all involved / Saya telah
memeriksa area kerja dan pencegahan yang diperlukan dan telah ……………………. …hours / jam ....................................... date / Tgl
dibahas oleh pihak-pihak terkait The in-coming Permit Holder and his workmen have been
satisfactorily briefed on all the hazards and precaution /
Pemegang ijin baru dan pekerjanya telah dijelaskan dengan rinci
tentang potensi Bahaya dan Pencegahannya
Outgoing Permit Holder / Pemegang Izin Lama :
-------------------------------------------------------------
Incoming Permit Holder / Pemegang Izin Baru :
Permit Holder / Pemegang Izin Kerja
---------------------------------------------------------------
11. De-Isolations / Electrical / Mechanical / 12. Suspension of Permit / Penundaan penggunaan Surat Izin Kerja
Pelepasan Isolasi Elektrik Mekanik I declare that the work for which this permit was issued has been
The electrical/mechanical isolations applicable to the Permit have temporarily suspended, all involved have withdrawn and the
now been removed / Isolasi Eektrik/Mekanik yang dipakai dalam izin area/ equipment has been left in a clean and safe state/ Saya
ini telah dihentikan menyatakan bahwa Surat Izin Kerja yang telah diterbitkan ini ditunda
pemakaiannya sementara waktu, semua pihak yang terkait ditarik,
Electrician / Ahli Listrik ......................................................... semua peralatan dan area kerja ditinggalkan dalam kondisi bersih dan
aman
Reason of suspension / Alasan Penundaan :
Mechanic / Ahli Mekanik .........................................................
Isolator / Di isolasi oleh .........................................................
Authorization Person / Penanggung Jawab :
BANYU URIP PROJECT
INFRASTRUCTURE FACILITIES EPC - 5
WORK PERMIT SYSTEM
Doc No. REV.
Health Safety Environment Page 3 of 3
IDBC-RH-SPZZZ-C00008 0
12. Work Completion / Penyelesaian pekerjaan 13. Permit Closure / Penutupan Izin Kerja
The above work has been completed. The worksite has been The work has been inspected and is complete. The Isolation have
left safe, clean, and tidy / Pekerjaan diatas dinyatakan selesai. been removed and the area is safe / Pekerjaan diatas telah diperiksa
Lokasi pekerjaan ditinggalkan dengan bersih, aman dan rapi dan selesai. Isolasi telah dihilangkan dan lokasi kerja dinyatakan
aman
………………………………..... …………………………
Authorized Person / Company (If Necessary) /
Permit Holder / Pemegang Izin Kerja ...................................... Penanggung Jawab Perusahaan jika perlu
Work Permit Extention Form / Form Perpanjangan Surat Izin Kerja
Sign
Date / Time / Tanda Tangan
No
Tanggal Jam Contactor Consortium General Client
Applicant HSE Superintendent Representative
1
2
3
4
5
6
7
Note :
Work Permit at any time may be revoked or reviewed if the performed does not
meet the requirements or provisions that safety required
Izin Kerja sewaktu-waktu dapat dicabut atau di tinjau ulang jika pekerjaan yang dilakukan
tidak memenuhi syarat atau ketentuan keselamatan yang disyaratkan
