WORK PERMIT CCSPC-WP-01
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PROJECT: CONTROL NO: _
LOCATION: DATE APPLIED:
POST THIS PERMIT AT THE WORK AREA
PERMIT HOLDER: DESIGNATION:
AREA/DEPARTMENT: CONTRACTOR:
TYPE OF WORK:
CONFINED SPACE EXCAVATION WORK HOT WORK ELECT’L/CHEM’L/MECH’L WORK
WORK AT HEIGHT LIFTING WORK OTHER
SPECIFIC WORK TO BE DONE: DATE OF WORK
FROM TO
SPECIFIC AREA OF WORK: TIME OF WORK
FROM TO
CHECKLIST OF REQUIRED DOCUMENT/S AND CERTIFICATE/S:
TRAFFIC MGT. CERT. GAS TEST CERTIFICATE SCAFFOLDING CERTIFICATE
LIFTING CERTIFICATE ELECTRICAL CERTIFICATE EXCAVATION CERTIFICATE
JOB HAZARD ANALYSIS (JHA) PRE-LIFT WORKSHEET LIFTING PLAN
SAFETY RISK ASSESSMENT EXCAVATION PLAN EMERGENCY PLAN
CHECKLIST OF WORKPLACE SAFETY PRECAUTION:
Ingress/Egress Fire Extinguisher/s Fire watch
Air intake/exhaust Lane Closure Road side protection
Warning Signs Lighting Barricade
LOTO Chem. Spill Containment Foreman/Leadman/Supervisor
Others:
WORK PERMIT CCSPC-WP-01
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PERSONAL PROTECTIVE EQUIPMENT:
RAIN BOOTS WELDING APRON WELDING HOOD WELDING MASK SAFETY EYEGLASS (DARK) SAFETY SHOES (GEN)
DUST MASK LAB APRON/ SUIT WELDING BOOTS GLOVES (COTTON) SAFETY EYEGLASS (CLEAR) SAFETY SHOES (W/MIDSOLE)
EAR MUFF CHEM SUIT RAINCOAT GLOVES (LEATHER) HARD HAT SAFETY SHOES (W/ >14KV RATING)
EAR PLUG FACE SHIELD RESPIRATOR GLOVES (MAONG) HARD HAT (UP TO 600V) FBH w/ DOUBLE LANYARD
COVERALL LAB SHOES REFLECTORIZED VEST GLOVES (ELECTRICAL) HARD HAT W/ High Voltage Req't SAFETY BELT (Fall Restraint)
SCBA OTHERS
VALIDITY: (MAXIMUM OF 7 CALENDAR DAYS)
This permit shall automatically revoked when an emergency alarm is activated and evacuation is in effect;
an accident in the permitted work area occurred; and/or non-existence of the designated Foreman, Lead-
man or Supervisor on the work area. SHE&S Focal Point shall issue Stop Work Authority.
This permit should be reviewed and/or renewed if conditions in this permit change i.e. manpower, work
environment, tools, equipment and materials.
PERMIT CONFIRMATION AND APPROVAL PERMIT CLOSE-OUT
I have read and understand the
PERMIT safety requirements of this
_
HOLDER permit and will comply. SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
I will ensure full compliance
CCSPC PROJ. with all the requirements of
SUPV. this permit and will exercise _ _
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
full supervision of the work
I confirm that safety
EHS OFFICER requirements of this permit
_ _
are in place and endorsing its SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
approval.
I have personally checked and
PROJ. MGR approved the precautions and
conditions listed above and _ _
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
authorize commencement of
the work
NO FOREMAN/LEADMAN/SUPERVISOR - NO WORK!
WORK PERMIT REVALIDATION
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7
FOREMAN/LEADMAN/SUPVSR
EHS OFFICER
PROJECT MANAGER
cc: Original- Permit Holder (to be posted on
site) EHS Officer
Security Officer
WORK PERMIT CCSPC-WP-01
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TRAFFIC MANAGEMENT CERTIFICATE
I have personally checked that the traffic management plan including installation of RECOMMENDED SAFETY MEASURES
safety barriers and road signs: O Use of lighting (type )
O has complied with the safe traffic requirement in preventing vehicle accident and O Use of PPE (type )
protection of the personnel working and within the vicinity of permitted area O Traffic re-routing
O may not be sufficient enough and shall be provided with additional precautions O Signages and barricades
O is not safe to perform assigned task O Standby Assistance (for rescue operation)
O
BY: NOTED BY: O
CONSTRUCTION/ELECT’L SUPV. / DATE PROJECT MANAGER / DATE
(Signature over Printed Name) (Signature over Printed Name)
SCAFFOLDING CERTIFICATE
Erected scaffolding was personally checked by me and certify that it is: RECOMMENDED SAFETY MEASURES
O Safe to use and perform specified job O Secure drop zone
O Safe to use and perform specified job following recommended safety measures O Use of FBH w/ double lanyard
O Not safe to perform specified job O Securely tied tools
O BP monitoring to personnel working @ ht.
O Daily inspection of scaffold
BY: NOTED BY: O Standby Assistance
O Rope, harnesses and/or wristlets
SCAFFOLD INSPECTOR / DATE PROJECT MANAGER / DATE O Others
(Signature over Printed Name) (Signature over Printed Name)
LIFTING CERTIFICATE
We conducted pre-use inspection I personally verified area of All required certificates Pre-lift meeting was conducted
of our equipment, tools, and lifting/ loading/ unloading and (operator, rigger & crane), and Lifting plan was established.
materials to be use and certify certify that working environment including JHA were submitted. After discussion with all
that: from ground to overhead is: Alcohol test before lifting was personnel concerned I certify
O Safe lifting activity can be O Safe to perform lifting activity also done and I certify that: that:
done O Safe to perform lifting activity O Safe lifting activity can be O Safe lifting activity can be
O Safe lifting activity can only following recommended safety done done
be done following recommended measures O Safe lifting activity can only be O Safe lifting activity can be
safety measures O Not safe to perform specified done following recommended done following recommended
O Lifting activity is not safe. job safety measures safety measures
O Lifting activity is not safe O Lifting activity is not safe
BY: BY:
CRANE OPERATOR / RIGGER PROJECT SUPERVISOR BY: BY:
(Signature over Printed Name) Signature over Printed Name) EHS Officer PROJECT MANAGER
(Signature over Printed Name) (Signature over Printed Name)
RECOMMENDED SAFETY MEASURES
O O
O O
WORK PERMIT CCSPC-WP-01
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ELECTRICAL CERTIFICATE
Machine, Tools, Equipment and/or / Facility was personally checked and tested by me RECOMMENDED SAFETY MEASURES
and certify that it is: O Isolate electrical energy using LOTO
O Safe to use and/or perform specified job O Isolate electrical energy using rubber insulator
O Safe to use and/or perform specified job following recommended safety measures O Use of multi-tester
O Not safe to perform specified job O Daily inspection of tools
O BP monitoring to personnel working @ ht.
BY: NOTED BY: O Buddy system
O Others
ELECTRICAL INSPECTOR / DATE PROJECT MANAGER / DATE O
(Signature over Printed Name) (Signature over Printed Name)
EXCAVATION CERTIFICATE
I have checked the site/studied the layout drawing and certify that the excavation: RECOMMENDED SAFETY MEASURES
O can be carried out without risk of damage to any underground services O Use of lighting (type )
O can be carried out provided that additional precautions are taken to prevent damage O Use of PPE (type )
to the equipment /services O Gas Testing
O is not safe to perform excavation O Shoring
BY: NOTED BY: O Signages and barricades
O Standby Assistance (for rescue operation)
CONSTRUCTION/ELECT’L SUPV. / DATE PROJECT MANAGER / DATE O
Signature over Printed Name) (Signature over Printed Name)
