Registration No:

PERMIT TO WORK
1.0 APPLICANT DETAILS
NAME: SIGNATURE : CONTACT No :
COMPANY : DESIGNATION:
2.0 ACTIVITY
GENERAL EARTH WORK HOT WORK WORKING AT HEIGHT
EXCAVATION GRATING / RALLING REMOVAL Wet Work / Cold Work
ELECTRICAL / INSTRUMENTATION WORK ROAD / ACCESS INTERUPTION LIFTING
STRUCTURAL ERECTION MECHANICAL WORK CONFINED SPACE
Heavy Lifting / Special Lifting OTHERS :
Note: Underlined & other critical activity's permit shall be valid for ONE (1) day ONLY.
3.0 DETAIL WORK DESCRIPTION

AREA : VALIDITY:
7 Days
START COMPLETION Pls refer to section
2.0 1 Days
TIME & DATE : TIME & DATE :
4.0 SUPPORTING DOCUMENT (S) E.g: JMS, JHA, Drawing & Etc.
1

5.0 SAFETY PRECAUTION & REQUIREMENT

SITE MANDATORY PPEs EARTHBUND AND GRADIENT ELECTRICAL ISOLATION CERT. NO.

GLOVES BARRICADE / SAFETY SIGNBOARDS MECHANICAL ISOLATION CERT. NO.

FACE PROTECTION CONDITION OF ROAD (I.E DRAINAGE) DUST CONTROL

HEARING PROTECTION CONDITION OF SLOPE TRAFFIC CONTROL

RESPIRATORY PROTECTION FIRE WATCHER, EXTINGUISHER, BLANKET LIGHTING

SAFETY HARNESS EQUIPMENT AND MACHINERY CHECKS OTHERS:

EXCAVATION SUPPORT

6.0 HAZARD IDENTIFICATION AND CONTROLS

HAZARDS CONTROL (S)

7.0 CONTRACTOR's AUTHORIZATION Main Contractor Reps

Department: RECEIVING AUTHORITY (RA) APPROVING AUTHORITY (AA)
SIGNATURE:
NAME :
POSITION :
DATE :
I (as named above) acknowledge that it is my responsibility to ensure that all persons engage in this work, weather employed directly or on
sub contracted; to execute their duties in safe manner while complying with the requirements of this permit.

8.0 Main Contractor's ACKNOWLEDGEMENT

Department: CM/PM/SPM/PD ACKNOWLEDGEMENT HSE ACKNOWLEDGEMENT
SIGNATURE:
NAME :
POSITION :
DATE :
9.0 COMPLETION DECLARATION BY APPLICANT
APPLICANT SIGNATURE :

(Name & Signature)

COMPLETION DATE & TIME :

NOTE : 1st copy:Job Site
1. All PTW to be submitted by cut-off time 4:00 p.m. 2nd Copy :Permit Controller
2. New PTW shall be re-applied for work before the set cut-off time. 3rd Copy : Applicant
3. JSA attached for the activity required to this PTW