PT.

PLN (Persero)
FORMULIR IZIN KERJA UMUM/
UPP KITRING KBB 4 GENERAL WORK PERMIT FORM

Safety Management System Doc. No : Rev. No :

Page 1 of 3 Date Rev :

Nomor izin/ ( Nomor ini diisi oleh pemilik proyek/perwakilan / This number filled by project
/GWP/PB/F-HSE/20 owner/representative)
Permit Number
Tanggal pengajuan/
Date submissions
URAIAN PEKERJAAN*/
WORK DESCRIPTION*
Nama pekerjaan/
Work name
No.SPK/Kontrak/Memo
No.WO/Contract/Memo
Departemen / Devisi
Department / Devision
Instansi / Nama perusahaan
Phone.
Instance / Company name
Nama manager proyek/
Phone.
Project manager name
Area / Lokasi kerja
Area/ work location
Lama pekerjaan/
............. Hari/Days ............................................... Sampai / to ................................................
Duration work days
Waktu Kerja Per Hari/
............. Jam/Hours .......................... Sampai / to .................................
Working time per day
Nama pengawas lapangan/
Phone.
Field Supervisor name
Jumlah pekerja/
............. Orang/Person
Total of workers
 Peralatan tangan / Hand  Alat berat/Alat angkat /  Mesin berputar/Bergerak /
tools Heavy equipment/Lifting Machine spinning / moving
 Truk/Trailer / Trailer/Truck equipment  Peralatan Listrik / Electric
 Bucket/Keranjang orang /  Kompresor / Compressor Equipment
PERALATAN YANG Man baskets/Bucket  Pompa portable / Portable  Welding machine / Welding
DIGUNAKAN/  Perancah / Scaffolding pump machine/Pressure cylinder
EQUIPMENT USED  Vakum / Vacuum  Alat Pengetesan / Tester  Lain-lain/Other .................
 Genset / Generator equipment ..........................................
 Pengaduk / Mixer

JENIS DAN KLASIFIKASI PEKERJAAN*

TYPE AND CLASSIFICATION OF JOB*
 Bekerja dibawah kabel listrik / Daerah
bertegangan listrik tinggi / Works under
power line / High-voltage electrical
area
 Pemasangan / Perakitan komponen
listrik / Installation / Assembling of
electrical components
 Instrumentasi / Instrumentation
 Penyambungan / Supply Connection
 Tali-temali & Pengangkatan / Rigging &
Lifting
 Isolasi / Isolation
 Perpipaan / Piping
 Bekerja di ketinggian >2 Mtr / Working  Penggalian / Excavation
at height >2 Mtr  Fabrikasi / Fabrication
 Konstruksi / Construction  Pemancangan / Piling
 Inspeksi / Pengecekan / Inspection /  Pengecatan/Sandblasting/
Checking Painting/Sandblasting
 Radiografi / Radiography  Transportasi/Pengepakan/
 Ruang terbatas / Confined space Transportation / Packaging
 Pengelasan/Kerja panas / Welding/Hot  Perawatan/Reparasi/
work Repair/Maintenance
 Pengujian/Komisioning / Testing /  Kerja tambahan/lembur/
Commissioning Work additional/Overtime
 Penanganan Limbah Kimia (B3) /  Lain-lain / Other ..........................
Chemical Waste Treatment (Hazard ....................................................
Material)

*Harap data dan keterangan pada formulir ini diisi secara manual/Please the data and details on this form are filled manually
 PT. PLN (Persero) FORMULIR IZIN KERJA UMUM/
UPP KITRING KBB 4 GENERAL WORK PERMIT FORM

Safety Management System Doc. No : Rev. No :

Page 2 of 3 Date Rev :

TINDAKAN PENCEGAHAN SEBELUM & SETELAH BEKERJA* /

PREVENTIVE ACTION BEFORE & AFTER WORK*
o Proteksi/Perangkat anti jatuh / o Sertifikat kompetensi / Certificate of
Protection/Anti fall device competence
o Pemadam api / Fire extinguisher o Mengikuti syarat HIRAC / JSA /
o Selimut penghambat api/Percikan / Following HIRAC / JSA requirements
Fire blancket / Spark o Memasang rambu keselamatan /
o Pelantar / Platform Peringatan / Pelabelan / Install safety
o Tangga / Ladders signs / Warning / Labeling
o Terpal / Penutup / Tarpaulins / Cover o Pembersihan / Housekeeping
o Sertifikat alat / Equipment certificate
o Tali pengaman / Pegangan tangan /
Safety ropes / Handrail
o Pagar / Barikade / Fences / Barricades
o Orang yg menerima/memberi aba-
aba / Signalman
o Lain-lain/Other ..............................
......................................................

TINDAKAN KESELAMATAN YANG LAIN DIPERLUKAN*/

OTHER SAFETY MEASURES ARE REQUIRED*

Harap mengikuti / Please follow:

 UU No. 1 Tahun 1970 / Law of Indonesian Republic Number 1/1970
 Peraturan : Menteri, Presiden dan pemerintah daerah / Regulations: Ministers, Presidents and local governments
 Metode kerja aman & HIRAC/JSA / Safe working methods & HIRAC / JSA
 SOP dan aturan proyek yang diberlakukan / Applicable standards operating procedure and project rules
 Dokumen Kontrak/ Surat keputusan / Contract Document/ Decree
 Standar indonesia atau standar internasional yang diberlakukan / Indonesian standards or international standards are enforced

Instruksi lainnya / Other instruction :

ALAT PELINDUNG DIRI YANG WAJIB DIGUNAKAN*/

PERSONAL PROTECTIVE EQUIPMENT THAT MUST BE USED*
o Helm / Helmet o Sarung tangan katun / Cotton gloves o Pelindung tubuh / Full body harness
o Kacamata / Safety Glasses o Sarung tangan karet / Rubber gloves o Rompi keselamatan / Safety Vest
o Sepatu Pelindung / Safety shoes o Masker / Mask o Cap pengelasan / Welding cap
o Sepatu Karet / Rubber boots o Respirator / Self Contained Breathing o Celemek / Apron
o Pelindung pendengaran/ Hearing Apparatus (SCBA) o Lain-lain/Other ...........................
protector / Ear Plug / Ear muff o Seragam penuh / Wearpack
LAMPIRAN / DOKUMEN YANG HARUS DISAMPAIKAN*/
ATTACHMENTS / DOCUMENTS TO BE SUBMITTED*
o Prosedur Uji Inspeksi / ITP (Inspection o Metode Kerja / SOP / Work o Data lembaran bahan berbahaya /
Test Procedure) methode/SOP MSDS
o Gambar Kerja / Work drawing o Spesifikasi : Produk/peralatan / o Dokumen lainnya (jika diminta) / other
o Identifikasi penilaian & pengontrolan Specifications: Product / equipment document (if requested)
bahaya/ HIRAC/JSA
Catatan / Note : Seluruh kelengkapan dokumen akan diperiksa oleh pemilik / perwakilan proyek / All documents will be checked by
the project owner / representative

PERSETUJUAN PEKERJAAN*/
*Harap data dan keterangan pada formulir ini diisi secara manual/Please the data and details on this form are filled manually
 PT. PLN (Persero) FORMULIR IZIN KERJA UMUM/
UPP KITRING KBB 4 GENERAL WORK PERMIT FORM

Safety Management System Doc. No : Rev. No :

Page 3 of 3 Date Rev :

APPROVAL OF WORK*
Pemohon Izin Kerja/
Work Permit Applicant
Pemilik / Perwakilan Proyek,
Project owner / representative

( .......................................... )
Field Supervisior
Diperiksa oleh/
Checked by,

( .......................................... ) ( ................................ ) ( ................................ ) ( ................................ )

HSE Officer - Contractor HSE Rep – HSE PLN E PLN UPP KITRING KBB 4
Date : Date : Date : Date :

Pastikan Petugas K3 dari perusahaan/kontraktor yang mengajukan izin kerja memeriksa terlebih dahulu seluruh kelengkapan dokumen
sebelum diajukan ke pemilik/perwakilan proyek / Ensure the Occupational Safety Officer of the company/contractor applying for a work
permit shall first check all the completeness of the documents before submitting to the project owner / representative

PENYELESAIAN PEKERJAAN*/
WORK COMPLETION*
Pekerjaan telah selesai pada Disampaikan Oleh/
PLN UPP KITRING KBB 4
tanggal / Work completed on : Submitted By :
Date :

Time:
Name & Sign: Date : Name & Sign : Date :

Tembusan / Copies :
- Penanggung jawab pekerjaan/ Person in charge of work
- Supervision Construction (HSE)
- PLN UPP KITRING KBB 4

*Harap data dan keterangan pada formulir ini diisi secara manual/Please the data and details on this form are filled manually