Ref. No.

: P20030-SWHP- -21

SAFETY ON WORKING AT HEIGHTS PERMIT FORM

Project Name GEM RESIDENCES Location
Contract Date and Time of
CP01
Package Inspection
Required
Actual Date and
Contractor BETONBAU PHIL., INC. Time of Inspection

Requested by EDJUN CAÑON / JHUNDEL PAJARILLAGA Inspected by JAMES GUATCHE / REGGIE AGUILUS
Contractor’s Engineer Contractor’s Engineer
CM Approving
Date
Permit

AREA

DATE PERMIT START START TIME DATE PERMIT END END TIME

SIGNATURES

CM CONTRACTOR CM CONTRACTOR

Please tick everything that applies

Work Area Equipment Requirement
Surface is stable Scaffold erected safely
Clear of tripping hazards Scaffold has controlled access
Clear of employees & visitors Tower scaffold erected correctly
Work area isolated Kickboards are intact
Access to work area is free Ladders is appropriate for the job
Access to work area is controlled Workers trained in the use of ladder
Measures taken to prevent tools from Ladder is certified for use.
dropping All equipment has been checked for
Fall Arrest the last 6 months
Safety lines certified safe and checked Reminders to Workers
Workers equipped with appropriate harness Not to over reach
Workers trained on how to use the harness Keep work area clear to prevent tools from
dropping
Weather Workers
Weather condition is cleared and Workers are trained on working at heights
monitored. Workers are not afraid of heights
Workers are medically qualified

F-OPS-091-0 EFF: 07/27/20 Page 1 of 1