Document No.
: KHI-HSE-F-018
Version: 7.0
Effective Date: May 2023
GENERAL PERMIT TO WORK-FACILITY MANAGEMENT
Permit Serial No: 2025/07/ST157/PTW065
SECTION 1: DETAILS (Complete all information)
Project Name: ADGM Square AL MAQAM TOWER 03 R2 PLUMBING PLANT
Exact Work Location:
ROOM
Facility Name: ADGM Square Facility Manager: Romar Emnace
Company Name: DCSERVE EQUIPMENT TRADING L.L.C Direct Supervisor jaison
Contact Name:
Direct Supervisor
Position: Site Engineer 0551233729
Contact Number:
Booster pump replacement in al maqam tower Risk Category (Low,
Brief Description of Work: Low
3 R2 plumbing plant Room Medium, & High):
Work Start Date: 05/07/2025 Work End Date: 31/07/2025
Work Start Time: 05:31 PM Work End Time: 08:36 AM
Client: Aldar Entity: Khidmah
SECTION 2: PERMIT REQUIREMENTS (tick all relevant boxes)
Confined Spaces Use of Scaffolding Hot Work (spark/heat) Use of MEWP (Scissor, Boom, etc.)
Use of Lifting machines Work with Lead Specialised Apparatus Work with Ladder
Work with Noise (85dB+) Excavations LOTO/Isolation of systems Work at Height above 1.8 Mtr.
Heavy Machinery Façade Cleaning Others (specify) : GENERAL WORK PERMIT
SECTION 3: SERVICES / AREAS AFFECTED (tick all relevant boxes)
Electrical / Mechanical HVAC Fire Systems Compressed Air
Drainage Water (Pot, CH, Irr) Gas Waste Systems (Evac)
Clubhouse / Mosque Residential Roads Other (Specify):
SECTION 4: SAFETY PRECAUTIONS TO BE TAKEN BY PERSONNEL (tick all relevant boxes)
Safety Helmet Eye Protection Hearing protection Safety Footwear
Safety Harness Fire Extinguisher Road Closure Alternative precautions
Area hand-over Elec / Mech. Isolations High Visibility Clothing Others (specify):
SECTION 5: SIGNATURES (in correct sequence)
Print Name: Signature: Date/Time:
I hereby confirm that the permit conditions and HSE precautions specified, will be implemented, maintained, supervised and adhered to at all times. I furthermore accept
that, any non-compliance with the HSE conditions, will result in revocation of the approved Permit.
Permit Applicant:
jaison 03/07/2025 04:16 PM
I hereby authorise the operations to proceeds subject to full compliance with the necessary safety precautions as per the above signature.
Permit Issuer (Khidmah Facility
Manager or Delegate)
Kesavan Sethusamy 07/07/2025 01:40 PM
HSE Dept. (or Site HSE Rep)
Jayakumar Plackal 07/07/2025 03:09 PM
Security In- Charge (Supervisor)
SECTION 6: PERMIT/ACTIVITY STATUS
Return to Khidmah Facility Manager (or Deputy) immediately on completion /abandonment of the work for closure, cancellation of the permit or for issue
of extension of the permit. Permits can only be extended once after initial approval, in order to complete the planned works. In case the permit has not
been returned, the permit is automatically cancelled, as per the Work End Date and Time.
Activity completed PTW expired PTW cancelled
Description:
PTW Extended Date/Time:
Permit Cancelled/closed
Date / Time Authorised by:
(if returned)
Note: The activity mentioned above is not under Khidmah Scope, this Permit is provided for access purpose only, Khidmah is not responsible for any kind
of incidents (Injury / Property damage) resulting out of the task performed by the contractor also Health & Safety implementations, monitoring and
responsibilities lies under the contractor / Tenant scope.
