GENERAL WORK PERMIT PERMIT
IJIN KERJA UMUM NUMBER:01/DBK/WP/HSSE/2023-S0
This permit may be applied maximum 1 day work with revalidated 12 hourly (Shift Changed)
Surat Ijin Kerja ini dapat digunakan maksimal 1 hari kerja dengan revalidasi setiap 12 jam (pergantian shift)
Date & Time :28.11.2023
Location :Dockyard Bagus Kuning Standby & Rescue Personnel
Tgl & Waktu
Issued To (Dikeluarkan ke) Specific Work Location (Spesifik Lokasi Kerja) Validation Period 1 Validation Period 2
Lapangan Dockyard Bagus Kuning
Department : Dockyard Validation Period : Time & Date: Pukul 08.00 to 17.00 Wib Tanggal 29.11.2023
Bagus Kuning Periode Masa Berlaku Jam Tgl.
Detailed description of work to be Pengangkatan dan Penurunan Menara di Area Lapangan Dockyard Bagus Kuning
performed:
Penjelasan detail dari pekerjaan
yang akan dilaksanakan
JOB REQUIREMENT (PERSYARATAN PEKERJAAN)
YES N/A CONTROLS COMMENTS CHECK ALL PPE REQUIRED
Equipment depressurised, drained and purged. √ Safety Helmet
Bejana tekan, buangan dan pelepasan. √ Safety Glasses
Equipment mechanical isolated (tagged and locked) Goggles
Peralatan mekanikal diberi tanda (tagged dan locked) Face shield
Equipment electrically isolated (tagged and locked) √ Safety shoes
Peralatan elektrik diberi tanda (tagged dan locked) Rubber boots
√ Work gloves
Warning signs posted at work point.
Beri tanda sed Hearing protection
√ Tanda peringatan ditempat kerja.
melakukan pekerjaan
√ Safety Harness
Gas test done-flammeble,poisonous & oxygent depletion.
√ Work vests
Test gas-mudah terbakar, beracun & pengurangan oksigen.
SCBA
Result/Hasil :…….. Respirator
√ Others.Coverall....
DANGER NOTICES AND ADDITIONAL
SAFETY EQUIPMENT REQUIRED :
Tanda-tanda bahaya dan tambahan
peralatan safety yang diperlukan
AUTHORISATION FOR WORK PERMIT TO BEGIN / Yang berwenang mengijinkan dimulainya pekerjaan
I hereby certify that it is safe to work on the following equipment.
Dengan ini saya menyatakan pekerjaan aman untuk dikerjakan sesuai dengan pelengkapannya
Permit Applicant Work Permit Authority Client Representative Controlling/Monitoring
Yang Memohon Yang Memberi Ijin Perwakilan Klien
Robert/ Pelaksana Muhammad/ GSI Bobi Candra Ilmansyah
………………………………….. …………………………………. …………………………………. ………………………………….
Name & Position Name & Position Name & Position Name & Position
REVALIDATION PERMIT
Pengesahan Ulang Ijin Kerja
Permit Applicant Work Permit Authority Client Representative Controlling/Monitoring
Revalidation Period
Shift Signature, Name & Signature, Name & Signature, Name & Signature, Name &
Time & Date: From …..to………..
Position Position Position Position
Dari Pukul 08.00 to 17.00 tanggal 30.11.2023 Pelaksana GSI CR Safety Inspektor
Robert Muhammad Bobi Candra Ilmansyah
AUTHORISATION FOR WORK PERMIT CLEARANCE / Yang berwenang untuk pemeriksaan ijin kerja
I hereby declare that the work for which this Permit was issued is now:
Dengan ini saya menyatakan pekerjaan yang tertera di ijin kerja ini, saat ini dalam status:
Permit Applicant Controlling/Monitoring COMPLETED/Telah selesai;
Work Permit Authority Client Representative
Signature, Name & Signature, Name & Time & Date:pukul 17.00 wib tgl. √
Signature, Name & Position Signature, Name & Position
Position Position 30.11.2023………………….
Pelaksana GSI CR Safety Inspektor
SUSPENDED/Ditunda ;
Time & Date:……………………..
Robert Muhammad Bobi Candra Ilmansyah
CANCELLED/Dibatalkan;
Time & Date:………………………
Copy: 1. White - Applicant 2.Pink - Permit Board Worksite 3. Blue - Area Authority 4. Yellow - File
