Project No.

P-JktGPG
GLOBAL PROJECT GROUP (GPG) Document No. P-JktGPG-100-15-FRM-0020
Revision 1
Page 1 of 2
PERMIT TO WORK FORM February 10, 2017
Issue Date

TYPE OF PTW ISSUED Hot work Working at height Excavation Energy Isolation Electrical
No:……….……………………………….. Confined Space Heavy Lifting Radiation / X - ray Cold Work
SECTION 1 - REQUISITION ( RESPONSIBLE PERSON )
Name requestor : Contractor Name : Permit Valid :
Day / Date : Location : From …….……………. To ……..……………
WORK DESCRIPTION

SECTION 2 - HAZARD / HAZARDOUS ( RESPONSIBLE PERSON )

No. Item Hazard 1st 2nd 3th 4th 5th 6th
1 Garvity hazard has been protected (working at height, working overboard, lifting, scaffolding, diving, etc.)
2 Motion hazard has been protected (lifting, crane activity, etc.)
3 Temperature hazard has been protected (hot surface, weather,, etc.)
4 Biological hazard has been protected (animal, bachteri, poor houskeeping, etc.)
5 Radiation hazard has been protected (x-ray, NTD, etc.)
6 Drop Object hazard has been protected (working with tools, scaffolding material, etc.)
7 Noise hazard has been protected (generator area, etc.)
8 Electrical hazard has been protected (electrical device, electrical tools, etc.)
9 Pressure hazard has been protected (hydrotest, pressure test, cylinder, etc.)
10 Mechanical hazard has been protected (rotation equipment, bending equipment, etc.)
11 Chemical hazard has been protected (flamable liquid, hydrocarbon, volatile liquid, cyanide, etc.)
12 Sharp Object hazard has been protected (material, tools, etc.)
13 Illumination hazard (ligthing, etc.)
14 Atmosphere hazard (O2 deficiency, LEL, H2S, etc.)
SECTION 3 - WORKSITE PREPARATION ( RESPONSIBLE PERSON )
Isolation / Blinded Area bariicade N2 prged / Ventilated Job pre-start meeting Escape way clear
Equipment depressurized Fire extinguisher Gas test required Worksite free of combustibles JHA
Warning sign Positive identification Scaffolding required Secure tools/material from falling Checklist
Additional Preparations : …………………………………………………………………………………………………………………………………………………………………………………
SECTION 4 - PERSONAL PROTECTIVE EQUIPMENT ( RESPONSIBLE PERSON )
MANDATORY RESPIRATORY PROTECTION EYE & FACE PROTECTION FALL PROTECTION BODY PROTECTION
Helmet Half Mask Respirator Googles Full Body Harness Chemical Suit
Safety Shoes Full Face Respirator Face Shield Fall Arrest Apron
Safety Glasses SCBA Welding Mask HAND PROTECTION OTHERS
Work clothing Dust Mask HEARING PROTECTION Hand Glove Personal O2 Monitor
Ear Plug / Muff Specific Hand Glove Life jacket / Life vest
SECTION 5 - MAINLY PRECAUSTION DONE ( RESPONSIBLE PERSON )
HEAVY LIFTING WORKING AT HEIGHT HOT WORK CONFINED SPACE
Lifting plan Follow WAH training Area free of flammable material Gas Test & Monitoring
Valid crane with valid certificate Fall prevention Fire Blanket Fire Retardant screen Walky Talky & Life line
Valid operator & rigger certificate Available of safe access Fire extinguisher Ventilation & Air surculation
Lifting sling and gear inspection Potential DROPs object Fire watcher Lighting
Pull push stick & tag line Rescue & Evacuation plan Electrical ground Competance person
Crane inspection checklist Fall protection Flush Open drain Rescue & Evacuation plan
Safe access Ventilation / Air surculation Supervisor & Entry watch
Safe working platform Standby emergency team
SECTION 6 - COMMUNICATION ( RESPONSIBLE PERSON )
Yes No Has the complete plan for safely conducting the work been effectively communicate to performing person ?
Yes No Does everyone clearly understand the plan and their responsibility ?
Yes No Have all performing person been adequately informed of the consequences and any precautions required ?

PERMIT DISTRIBUTION :- Top Copy - Displayed at Work Site 2nd Copy - HSE Room 3rd Copy - Responsible Person

NO WORK IS SO URGENT THAT WE CANNOT TAKE THE TIME TO DO IT SAFELY `