PERMIT TO WORK PTW NO :

1) DETAILS (Tick Applicable Boxes)

A. COMPANY

PESG CONTRACTOR :

B. TYPES OF WORK

HOT WORK ENERGY ISOLATION WORKING AT HEIGHT

C. DETAILS OF WORK

Description :

Location :

No of Pax :

D. WORK HAZARDS

Line of fire Pinch points High Noise Geohazard

High Pressure Chemical Exposure Sharp objects Drilling hazard
Severe Weather Heavy lifting Repetitive Motion Electrocution
Gas release Falling Objects Sources of Ignition
Limited access/egress Slippery surface Mechanical lifting

Others :

E. PERSONNEL PROTECTIVE EQUIPMENT (PPE)

Safety Helmets Suitable Gloves REQUIREMENTS: Coverall, Safety Helmets, Safety Shoes and Safety Glass
Coverall Life Jacket/Work vest are MANDATORY in PPE Zone.
Ear Muffs / Ear Plugs Body Harness and Lanyards
Safety shoes Dust Mask / Respirator
Goggles / Face Shield / Chemical Suit
Welding Shield

Other:

F. ADDITIONAL DOCUMENTS REQUIRED TO ACCOMPANY PERMIT TO WORK FORM

Job Hazard Analysis (JHA) Safety System Isolation / Lock Out - Tag Out
Radiation Certificate Electrical Permit To Work
Excavation Certificate Electrical Isolation Certificate
Lifting Certificate Safety Checklist
Gas Test Certificate Scaffolding Certificate
Method Statement (Scope of Work) Confined Space Entry Certificate

Other:

G. WORK PERMIT SPECIAL PRECAUTIONS

Standby man / fire watcher must be in attendance at all times Others:

Safety system / alarm to be tagged and overide
Hazardous Drains or Vents in vicinty to be isolated
Gas, Flame and Smoke Detections to be marked or isolated
Combustible Materials removed or protected

2) VALIDITY

1 This permit is only valid for specific time frame ( refer below time figures ).
2 Regular check for the safe operation to be done hourly or when required by Supervisor.
3 For Hot Work, Entry Into Confined Space, and Working at Height required company authorisation approval.

12 hours(1 SHIFT) 24 hours(1 DAY) Remarks:

IMPORTANT NOTE:
THIS PERMIT IS AUTOMATICALLY SUSPENDED WHEN THE "EMERGENCY ALARM" IS ACTIVATED. WORK MUST BE STOPPED, WORK AREA MUST BE MADE SAFE AND THE PERMIT
RETURNED TO AUTHORITY. THIS PERMIT MUST BE RE-VALIDATED BY APPROVING AUTHORITY BEFORE RECOMMENCE THE JOB.

3) AUTHORIZATION

A. PERMIT APPLICANT B. AUTHORISED SUPERVISOR C. APPROVING AUTHORITY

Sign: Date: Sign: Date: Sign: Date:

Name: Time: Name: Time: Name: Time:

4) COMPLETION

A. PERMIT APPLICANT B. AUTHORISED SUPERVISOR C. APPROVING AUTHORITY

Sign: Date: Sign: Date: Sign: Date:

Name: Time: Name: Time: Name: Time:

Original : Control Room / Bridge Work location Permit Applicant