PERMIT TO WORK

Rev. : 0
[ ] Working at Height [ ] deep excavation [ ] Hot work

Page 1 of 2

A. DESCRIPTION OF WORK OTHER INFORMATION

Type of High Risk Work. Requested by
*Classification refer to Part 'B' (Name &
Project: Designation)
PEMBINAAN 2 BLOK GANTIAN 6 BILIK
DARJAH DAN LAIN-LAIN KEMUDAHAN
DI SEKOLAH MENENGAH KEBANGSAAN Application Date
TENGKU AMPUAN INTAN, KUALA
BERANG, HULU TERENGGANU, TRG.

Number of Workers
Location:

Job Commencement
& Completion Date
Work / Trade:
B. APPROVAL

I have * reviewed the method statement / construction method and found to be sufficient.

* requested the applicant to carry out necessary safety and environmental protection measures
such as:

* barricated the area / a warning-signage.

* briefed workers on safety rules and regulations (and P.P.E).

* assigned ……………………………..…………….………………….
& ………………..………………………………………..………………..
to standby

Approved by :

Site Safety Supervisor

Name:
Date :
 Permit To Work

[ ] At Height [ ] Deep Excavation [ ] Hot work Rev: 0

Page 2 of 2

C. VERIFICATION / PRECAUTIONS TAKEN

HOT WORK i. Fire blanket provided Not Applicable / Yes / No

A
(including cutting by oxygen ii. Fire extinguisher provided Not Applicable / Yes / No
flame or cutting m/c, brazing by iii. Any chemicals or combustible
oxy-acetylene flame. materials around Not Applicable / Yes / No

B DEEP EXCAVATION i. Driver / operator holds Class H

MORE THAN 1.5m. driving license Not Applicable / Yes / No
ii. Barricade with reflective markings
/ barrier strips Not Applicable / Yes / No
iii. Underground cables/piping have
been identified. Not Applicable / Yes / No
iv. Signages Not Applicable / Yes / No

C SCAFFOLD i. Exceeding 15m height - P.E

MORE THAN 5.0m HIGH approved design. Not Applicable/Yes/No
ii. Erected by DOSH approved
competent person. Not Applicable/Yes/No

D. COMPLETION OF THE JOB

i) All equipment / tools / chemicals / gas cylinders removed from place of work. Yes / No
ii) Rubbish / debris / scraps removed and cleared from the place of work. Yes / No

Verified by:

PM/CM
Name :
Date :