UMM WU’AL PHOSPHATE
PROJECT.
ELEVATED WORK PERMIT
PERMIT NO. COMPANY: PROJECT:
DATE: TIME: DATE/TIME EXPIRES:
LOCATION: AREA:
Section A: PRIOR TO START OF ELEVATED WORK
ENSURE THAT THE FOLLOWING CRITERIA ARE MET
Cables/cords are raised 6ft. above surface
Y N N/A 100% Fall Protection complied. Y N N/A
and safety flags are provided.
Scaffolds are complete and tagged safe for Walkway is clear of scattered debris, tools
Y N N/A Y N N/A
use. and materials.
Access is clear and free of obstruction. Access Gas cylinders secured or mounted on a
Y N N/A Y N N/A
ladder is secured and free of defects. trolley or rack.
Full body harness with 2 lanyards and shock absorber worn Open areas are adequately covered and protected.
Y N N/A Y N N/A
where required. 100% PPE compliance. Warning signs are conspicuously posted
Hot Work/Cold Work permit completed Vertical ladder is not allowed. For elevation higher
Y N N/A Y N N/A
where required. than 12ft. side step scaffold is required.
Fire blanket/welding screen for welding,
Y N N/A Safety Officer designated to the area. Y N N/A
cutting/grinding works provided.
Safe Work Plan submitted alongside with Elevated work will not be performed above
Y N N/A Y N N/A
elevated work permit. fuel driven equipment.
Proper and adequate housekeeping is Elevation Work has safe access and egress
Y N N/A Y N N/A
maintained. and secures anchor points.
Section B: AUTHORIZAITON TO PROCEED WITH ELEVATED WORK
This is to certify that the above criteria are satisfactorily met and related work permits and safe work plans are
completed.
TASK SUPERVISOR ZONE MANAGER/PROJECT ENGINEER
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
APPROVED BY:
NESMA AREA SAFETY SUPERVISOR/SITE SAFETY SUPERVISOR NESMA CONST. MANAGER/AREA MANAGER
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
Section C: AFTER COMPLETION OF ELEVATED WORK
Y N No material and tools are left lying on walk-ways Y N Barricades are installed and appropriate signs posted.
Y N Debris, trash and spent welding rods/stubs are removed. Y N Extension cords are rolled up and secured.
Y N Extension cords are rolled up and secured. Y N Access ladder secured and free of obstruction.
Y N All electrical equipment has been unplugged. Y N
This is to certify that a post-work inspection of the area was completed and found safe and secured.
Task Supervisor: Safety Supervisor:
Signature: Date: Signature: Date:
NOTE:
1. APPROVED ELEVATED WORK PERMIT MUST BE CONSPICUOUSLY POSTED AT ACCESS POINT.
2. SUBMIT WITH SAFE WORK PLAN.
3. THIS ELEVATED WORK PERMIT IS VALID ONLY FOR ONE SHIFT.
Attachment B
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
SAFE WORK PLAN
CONTRACT #: LOCATION: AREA:
MANPOWER: COMPANY: DATE:
RESPONSIBLE SUERPVISION (Please Print Name)
PROJECT ENGINEER SUPERVISOR FOREMAN
DESCRIPTION OF THE WORK:
S/N HAZARDS CONTROL MEASURES
OTHER HAZARDS: ADDITIONAL SAFEGUARDS:
ATTACHMENTS:
PROJECT ENGINEER: SAFETY SUPERVISOR:
SIGNATURE: DATE: SIGNATURE DATE:
Attachment A
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
SAFETY STOP WORK ORDER
DANGER: Y N COMPANY:
LOCATION: AREA:
DESCRIPTION OF NONCOMFORMANCE:
DISPOSITION:
SAFETY SUPERVISOR/REPRESENTATIVE: SUPERVISOR/FOREMAN:
NAME: NAME:
SIGNATURE: DATE: SIGNATURE: DATE:
ACTION VERIFIED AND SWO CLOSED BY
SAFETY SUPERVISOR/REPRESENTATIVE: SUPERVISOR/FOREMAN:
NAME: NAME:
SIGNATURE: DATE: SIGNATURE: DATE:
Attachment C
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
SCAFFOLD PERMIT
Contractor: Area: Date:
Permit#: Specific Location: Scaffold Number:
Supervisor: Builder:
Purpose of Scaffold: Length of Time Needed:
Type of Scaffold: Maximum Number of Personnel Permitted:
Height: Length at Base:
Width at base: Load Limit Maximum = Total KG:
Y N
Light Duty
Medium Duty
Special Duty
NOTE: If a specialty scaffold or an engineer designed scaffold, the design drawing and specifications must be
attached.
PRE-ERECTION APPROVALS
The Signatories below agree to the information above.
User: Date: Scaffold Supervisor: Date:
Safety Supervisor: Date: Project Engineer: Date:
SCAFFOLD COMPLETION
By signing here the scaffold builder verifies that the scaffold is complete, the scaffolding supervisor verifies that he
was conducted an inspection and confirms that the scaffold is complete and that is it being build according to the
information on this document and that the scaffold is ready for inspection. The user signs verifying that the scaffold is
built according to his needs.
Scaffold Builder: ______________________________________ Date Completed:___________________
Scaffolding Supervisor: _________________________________ Date:____________________________
Scaffold User: ________________________________________ Date: ____________________________
AFTER ERECTION INSPECTION AND APPROVAL
By signing below the scaffolding inspector and the competent scaffold supervisor certified that the scaffold is
complete, meets all the scaffolding and safety criteria and that it is safe for use. The scaffold inspection form must be
used for the inspection of the scaffold. A completed green/yellow SCAFTAG must be attached to the scaffold at the
access point with the scaffold number written on the SCAFTAG. (In case of a specialty scaffold or engineered design
scaffold 12 meter and above in height, the scaffolding Inspector must sign).
Competent Scaffold Supervisor:_____________________________ Date:____________________________
Scaffold Inspector:________________________________________ Date:____________________________
IF ALARM IS SOUNDED, THIS PERMIT IS CANCELLED
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
COLD WORK PERMIT
PERMIT NO. COMPANY: PROJECT:
START DATE: FINISH DATE: TIME FROM: TO:
LOCATION: AREA:
PART A Brief Description of Work Involved: Other personnel engaged in the work:
Erection and dismantling of scaffold/Excavation, Backfilling and Flagmen
compaction. Installation of re-bar, Shuttering, carpentry, masonry Riggers
works. Installation and dismantling of formworks. Rigging and slinging HSE/Supervisors/General Foreman
and lifting. Pouring of concrete. Duct Bank Works. Installation and Concrete Pump Operator’s
dismantling of Tower Crane, etc. Equipment/Delivery Drivers
Authorized Person: Position/Department: Phone#:
PART B HAZARD IDENTIFICATION (Tick where appropriate)
Cables/cords are raised 6ft. above surface
Y N N/A Pre Job Start Meeting Y N N/A
and safety flags are provided
Walkway is clear of scattered debris, tools
Y N N/A Emergency Instruction Required Y N N/A
and materials
Access is clear and free of obstruction. Access
Y N N/A Y N N/A Barriers & Protection Required
ladder is secured and free of defects.
Full body harness with 2 lanyards and shock absorber Open areas are adequately covered and protected.
Y N N/A Y N N/A
worn where required. 100% PPE compliance. Warning signs are conspicuously posted
Safe Work Plan submitted alongside with
Y N N/A Y N N/A Fire Extinguishers Required
cold work permit.
Information of other affected personnel is
Y N N/A Working Alone Y N N/A
required.
Elevated work will not be performed above
Y N N/A Illumination Required Y N N/A
fuel driven equipment.
Proper and adequate housekeeping is Elevation Work has safe access and egress
Y N N/A Y N N/A
maintained. and secures anchor points.
Mandatory Safety Requirement/Local Hazards/Precautions to be taken
PART C Sub Contractor Acceptance: I accept responsibility for the work/personnel started. Agree to implement safe
working procedures and confirm that all personnel are adequately trained and will work only on the
job/equipment specified.
SUB CONTACTOR PROJECT MANAGER/CONST.MANAGER SUB CONTACTOR SAFETY REPRESENTATIVE
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
APPROVED BY:
NESMA AREA SAFETY SUPERVISOR/STIE SAFETY SUPERVISOR NESMA CONST. MANAGER/PROJECT LEAD ENGG.
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
NOTE: 1. This permit must be submitted to the NESMA SAFETY DEPT. before 24 hrs.
2. The copy of work permit must be placed at the work location.
3. Fail to comply safety requirement, the work shall be stopped.
4. If work is required on elevated areas Elevated Work Permit shall be taken.
5. Attachment –
IF ALARM IS SOUNDED, THIS PERMIT IS CANCELLED
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
HOT WORK PERMIT
PERMIT NO. COMPANY: PROJECT:
START DATE: FINISH DATE: TIME FROM: TO:
LOCATION: AREA:
PART A Brief Description of Work Involved: Other personnel engaged in the work:
Grinding, Welding and Fabrication Work HSE/Supervisors/General Foreman
Man-lift Operator
Equipment/Delivery Drivers
FIRE WATCH; see Attached Sheet
Authorized Person: Position/Department:
Cables/cords are raised 6ft. above surface
Y N N/A Pre Job Start Meeting Y N N/A
and safety flags are provided
Walkway is clear of scattered debris, tools
Y N N/A Emergency Instruction Required Y N N/A
and materials
Access is clear and free of obstruction. Access
Y N N/A Y N N/A Barriers & Protection Required
ladder is secured and free of defects.
Full body harness with 2 lanyards and shock absorber Open areas are adequately covered and protected.
Y N N/A Y N N/A
worn where required. 100% PPE compliance. Warning signs are conspicuously posted
Safe Work Plan submitted alongside with
Y N N/A Y N N/A Fire Extinguishers Required
cold work permit.
Information of other affected personnel is
Y N N/A Working Alone Y N N/A
required.
Elevated work will not be performed above
Y N N/A Illumination Required Y N N/A
fuel driven equipment.
Proper and adequate housekeeping is Elevation Work has safe access and egress
Y N N/A Y N N/A
maintained. and secures anchor points.
Fire Extinguishers and 110V power
Y N N/A Welding Screen, Fire Blanket, Face shield Y N N/A
equipment required.
Mandatory Safety Requirement/Local Hazards/Precautions to be taken
PART C Sub Contractor Acceptance: I accept responsibility for the work/personnel started. Agree to implement safe
working procedures and confirm that all personnel are adequately trained and will work only on the
job/equipment specified.
SUB CONTACTOR PROJECT MANAGER/CONST.MANAGER SUB CONTACTOR SAFETY REPRESENTATIVE
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
APPROVED BY:
NESMA AREA SAFETY SUPERVISOR/STIE SAFETY SUPERVISOR NESMA CONST. MANAGER/PROJECT LEAD ENGG.
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
NOTE: 1. This permit must be submitted to the NESMA SAFETY DEPT. before 24 hrs.
2. The copy of work permit must be placed at the work location.
3. Fail to comply safety requirement, the work shall be stopped.
4. If work is required on elevated areas Elevated Work Permit shall be taken.
5. Attachment –
IF ALARM IS SOUNDED, THIS PERMIT IS CANCELLED
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
COLD WORK PERMIT
PERMIT NO. COMPANY: PROJECT:
START DATE: FINISH DATE: TIME FROM: TO:
LOCATION: AREA:
PART A Brief Description of Work Involved: Other personnel engaged in the work:
Erection and dismantling of scaffold/Excavation, Backfilling and Flagmen
compaction. Installation of re-bar, Shuttering, carpentry, masonry Riggers
works. Installation and dismantling of formworks. Rigging and slinging HSE/Supervisors/General Foreman
and lifting. Pouring of concrete. Duct Bank Works. Installation and Concrete Pump Operator’s
dismantling of Tower Crane, etc. Equipment/Delivery Drivers
Authorized Person: Position/Department: Phone#:
PART B HAZARD IDENTIFICATION (Tick where appropriate)
Cables/cords are raised 6ft. above surface
Y N N/A Pre Job Start Meeting Y N N/A
and safety flags are provided
Walkway is clear of scattered debris, tools
Y N N/A Emergency Instruction Required Y N N/A
and materials
Access is clear and free of obstruction. Access
Y N N/A Y N N/A Barriers & Protection Required
ladder is secured and free of defects.
Full body harness with 2 lanyards and shock absorber Open areas are adequately covered and protected.
Y N N/A Y N N/A
worn where required. 100% PPE compliance. Warning signs are conspicuously posted
Safe Work Plan submitted alongside with
Y N N/A Y N N/A Fire Extinguishers Required
cold work permit.
Information of other affected personnel is
Y N N/A Working Alone Y N N/A
required.
Elevated work will not be performed above
Y N N/A Illumination Required Y N N/A
fuel driven equipment.
Proper and adequate housekeeping is Elevation Work has safe access and egress
Y N N/A Y N N/A
maintained. and secures anchor points.
Mandatory Safety Requirement/Local Hazards/Precautions to be taken
PART C Acceptance: I accept responsibility for the work/personnel started. Agree to implement safe working
procedures and confirm that all personnel are adequately trained and will work only on the job/equipment
specified.
TASK SUPERVISOR ZONE MANAGER/PROJECT ENGINEER
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
APPROVED BY:
NESMA AREA SAFETY SUPERVISOR/SITE SAFETY SUPERVISOR NESMA CONST. MANAGER/AREA MANAGER
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
NOTE: 1. This permit must be submitted to the NESMA SAFETY DEPT. before 24 hrs.
2. The copy of work permit must be placed at the work location.
3. Fail to comply safety requirement, the work shall be stopped.
4. If work is required on elevated areas Elevated Work Permit shall be taken.
5. Attachment –
IF ALARM IS SOUNDED, THIS PERMIT IS CANCELLED
JABAL OMAR DEVELOPMENT
PROJECT-MAKKAH
HOT WORK PERMIT
PERMIT NO. COMPANY: PROJECT:
START DATE: FINISH DATE: TIME FROM: TO:
LOCATION: AREA:
PART A Brief Description of Work Involved: Other personnel engaged in the work:
Grinding, Welding and Fabrication Work HSE/Supervisors/General Foreman
Man-lift Operator
Equipment/Delivery Drivers
FIRE WATCH; see Attached Sheet
Authorized Person: Position/Department:
Cables/cords are raised 6ft. above surface
Y N N/A Pre Job Start Meeting Y N N/A
and safety flags are provided
Walkway is clear of scattered debris, tools
Y N N/A Emergency Instruction Required Y N N/A
and materials
Access is clear and free of obstruction. Access
Y N N/A Y N N/A Barriers & Protection Required
ladder is secured and free of defects.
Full body harness with 2 lanyards and shock absorber Open areas are adequately covered and protected.
Y N N/A worn where required. 100% PPE compliance. Y N N/A Warning signs are conspicuously posted
Safe Work Plan submitted alongside with
Y N N/A Y N N/A Fire Extinguishers Required
cold work permit.
Information of other affected personnel is
Y N N/A Working Alone Y N N/A
required.
Elevated work will not be performed above
Y N N/A Illumination Required Y N N/A
fuel driven equipment.
Proper and adequate housekeeping is Elevation Work has safe access and egress
Y N N/A Y N N/A
maintained. and secures anchor points.
Fire Extinguishers and 110V power
Y N N/A Welding Screen, Fire Blanket, Face shield Y N N/A
equipment required.
Mandatory Safety Requirement/Local Hazards/Precautions to be taken
PART C Acceptance: I accept responsibility for the work/personnel started. Agree to implement safe working
procedures and confirm that all personnel are adequately trained and will work only on the job/equipment
specified.
TASK SUPERVISOR ZONE MANAGER/PROJECT ENGINEER
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
APPROVED BY:
NESMA AREA SAFETY SUPERVISOR/SITE SAFETY SUPERVISOR NESMA CONST. MANAGER/AREA MANAGER
NAME (Please Print): NAME (Please Print):
SIGNATURE: DATE: SIGNATURE: DATE:
NOTE: 1. This permit must be submitted to the NESMA SAFETY DEPT. before 24 hrs.
2. The copy of work permit must be placed at the work location.
3. Fail to comply safety requirement, the work shall be stopped.
4. If work is required on elevated areas Elevated Work Permit shall be taken.
5. Attachment –
IF ALARM IS SOUNDED, THIS PERMIT IS CANCELLED
