PTW number /

K371 - RIJEKA REFINERY UPGRADE PROJECT Broj DZR:

AREA HOT - PERMIT TO WORK /DOZVOLA ZA RAD S VATROM

Part I: Work Details (To Be Filled by WORK EXECUTOR) / I. dio: Opis posla (Ispunjava IZVODJAC RADOVA)
Application Date: Start Date & Time: Completion Date & Time: Executing Company (MAIN SUBs / SUB-SUB): Layout/ Sketch Attached
Datum Aplikacije: Datum / Vrijeme Pocetak: Datum i vrijeme zavrsetka: Izvodjac radova (IZV / PODizv) Nacrt / Skica

18.02.2022. 23.02.2022. 7:30 09.03.2022. 19:00 IVICOM/POMGRAD YES X NO

Tools & Equipment to be used: / Alati i Oprema:

hand tools, electrical hand tools (grinder, drlling tool), ladder, pliers, mechanical hand tools
SILOS/SILO Ručni alat, ručni električni alat (bušilica, brusilica), ljestve, kliješta, bužir, nivelir

JSA and WMS code and

Ref. to EMPLOYER PTW: Number of workers:
Title: Postavljanje kontejnera, tesarski radovi, geodetski radovi BROJ DZR INA: Broj radnika: 12
JSA & WMS Broj i Naslov:

Describe Exactly Work to be

done: / Pozicioniranje kontejnera, tesarski radovi, priprema kontejnerskog naselja, geodetske izmjere, /
container positioning, carpentery work, preparation of container settlement, geodetic surveying,
Detaljan opis posla:

Part II - Specific Safety Precaution (To Be Filled by WORK EXECUTOR) / II. Dio: Sigurnosne Mjere: (Ispunjava IZVODJAC RADOVA)
Personal Precautions / Osobne zastitne Work Safety Precautions Supporting PTW, Documents or Isolations Required
YES NO NA YES NO NA Dodatna dokumentacija / izolacija / DZR YES NO NA
mjere Zastitne mjere za djelatnost
Fire Retardant Clothing / Are Any Additional PTW Required / LOTO for electrical energy sources?
Vatrootporna odjeca X Dodatna DZR: X LOTO za elektricni izvor energije X
LOTO for mechanical energy sources?
Safety Shoes / Zastitna Obuca X JSA Prepared / Procjena rizika za djelatnost X LOTO za mehanicke izvore energije X
Safety Helmet with chin strap / Simultaneous Operations. (SIMOPS).
Zastitna kaciga sa remenom za bradu X LMRA to be Undertaken / LMRA mora biti provedena X Simultane operacije (SIMOPS) X
Safety glass (clear or dark) / Provide appropriate signages and barricades / Confined Space Entry Permit /
Zastitne naocale transparentne ili tamne X Postavljanje sigunosnih oznaka I barikada: X DZR za ulazak u skuceni prostor X
High reflective vest / Equipment inspected for use Hot Work Permit
Reflektirajuci prsluk X Oprema pregledana X Crvena DZR X
Is Forced ventilation necessary Excavation Permit
Standard gloves / Zastitne Rukavice X Ventiliranje / prozracivanje X DZR za iskope X
Heat resistant gloves / Provide adequate lighting Critical Lifting Permit
Rukavice sa toplinskom zastitom X Propisno osvijetljenje X DZR za podizanje kriticnih tereta X
PVC gloves/ Ensure Safe Access HSE permanent monitoring
PVC rukavice X Sigurnosni pristup / ulaz X Stalni HSE nadzor X
Full body safety harness / Radiography
Zastitni pojas za cijelo tijelo X Spark-free tools (Bronze) / Neoskreci alat (Bronc X Radiografija X
Hearing Protection / Intrinsically safe radios/ phones Night or Out Of Hours Permit
Zastita sluha X Radio / Mobiteli u EX- izvedbi X DZR za prekovremeni rad / noc X
Face Shield / Floor Grating Removal
Zastitni vizir X Fire Proof Blanket / Vatrootporni pokrivaci X Uklanjanje podnih resetki X
Welding Leathers / Pressure Testing Permit
Zavarivacka navlaka X Fire Extinguisher / Vatrogasni aparat X DZR za tlacnu probu X
Rescue Equipment Pre Commissioning or Commissioning /
Life line / Povezno uze X Oprema za spasavanje X Pred pustanje i Pustanje u pogon X
High impact gloves / Rukavice sa zastitom Fire Watcher Required /
od udarca X Nadzor Vatrogasca X
Executor is certified (AV012) for extinguishing small fires (when
Other PPE / Ostala OZO:
no: works can’t be started)
djelatnici osposobljeni za pocetno gasenje pozara, ukoliko nisu X
aktivnost ne moze zapoceti

Others /
HAZARDS: H2S, TRIPS, SLIPS, FALLING WEATHER CONDITIONS, ADJACENT WORKS, GRAITING/ HANDRAILS REMOVAL , PRESENCE CABLES AND PIPES, ENERGIZED PANEL
Ostalo:
PRECAUTIONS: WORKING ALONE FORBIDDEN, CONTINUOUS GAS TESTING WITH ROBOT, DEENERGIZED PANEL BEFORE
I am aware of the conditions on this permit, they have been discussed with the WORK EXECUTOR and I confirm that the safety precuations as attached to the PTW and certificates will be strictly observed. All personel under my control shall be
briefed through LMRA accordingly. I will notify the Permit Issuing Authority upon suspension/completion of this work.
Upoznat sam sa uvjetima iz DZR koji su preneseni IZVODJACU RADOVA i potvrdjujem da ce se sve zastitne mjere u DZR i prilozeni certifikati detaljno promotriti i primjeniti.
Potvrdjujem da ce svi djelatnici pod mojoj ingerencijom proci LMRA. U slucaju zatvaranja ili suspenzije DZR odmah cu obavijestiti izdavatelja DZR.

WORK EXECUTOR /
IZVODJAC RADOVA Date / Signature /
Name&Surname
MARIJA BOŽIĆ 23.02.2022. Tel.:
Datum: Potpis:
(readable):

MAIN
SUBCONTRACTOR /
Date / Signature /
GLAVNI IZVODJAC MARIJA BOŽIĆ 23.02.2022. Tel.:
Name&Surname Datum: Potpis:
(readable):

Part III - COORDINATION/INTERFERENCES Notifications (To be filled by Contractor Issuing Authority Responsible for the Activity and Signed SUPPLIER) /
III Dio - KOORDINACIJA / OBAVJESCENOST Upute (Ispunjava Izdavatelj DZR - Odgovorna osoba za aktivnost i potpisuje dobavljac)

CONTRACTOR Electrical & CONTRACTOR Lifting

CONTRACTOR Mechanical CONTRACTOR Commissioning CONTRACTOR QA & QC
CONTRACTOR Civil Instrumental Superintendent/
Superintendent/ Superintendent/ Superintendent/ Other as required by CIA /
Superintendent/ Superintendent/ Supervisor
Supervisor Supervisor Supervisor Na zahtjev izdavatelja DZR -Potpisnik po
Supervisor Supervisor GLAVNI IZVODJAC
GLAVNI IZVODJAC GLAVNI IZVODJAC GLAVNI IZVODJAC potrebi
GLAVNI IZVODJAC Supervisor GLAVNI IZVODJAC Supervisor za podizanje
Mehanicki Supervisor Commisioning Supervisor QA / QC Supervisor
Elektricarski Supervisor tereta

COMPANY / COMPANY / COMPANY /2

Other SUPPLIERs / CONTRACTOR YES NO
TVRTKA TVRTKA TVRTKA
Superintendent/Supervisor to be
notified / 3
Obavijestavanje KORISNIKA / Name Sign Name Sign Name Sign
GL. IZVODJACA : Ime Potp Ime Potp Ime Potp

Part IV - Acceptance (To be filled by Contractor Issuing Authority) / IV Dio - Potvrda (Ispunjava Izdavatelj DZR )
CIA confirms that all requirements of the permit have been met and the work can be carried out safely under the above conditions. /
IZDAVATELJ DZR potvrdjuje da su svi zahtjevi ispunjeni i da se radovi mogu izvoditi na siguran nacin
Name&Surname (readable): of
CIA / Date/Time / Sign./
Ime i prezime (citko)
7/02/2022
Datum/Vrijeme: Potpis:
IZDAVATELJ DZR:
 PTW number /
K371 - RIJEKA REFINERY UPGRADE PROJECT Broj DZR:

AREA HOT - PERMIT TO WORK /DOZVOLA ZA RAD S VATROM

Part V - Issue and Validity (To be filled by CONTRACTOR HSE PTW COORDINATOR) / V Dio - Izdavanje (Ispunjava HSE DZR
Koordinator)
CONTRACTOR HSE PTWC
Valid from / Time / Date / Time /
23.02.2022. name: NEVEN PRIJIĆ
Vrijedi od: Vrijeme: Datum: Vrijeme:
HSE DZR Koordinator:
Valid up to / Time / Signature /
09.03.2022.
Vrijedi do: Vrijeme: Potpis:

Others /
Ostalo: All works performed on ladders above 1m- fall protection system / full body harness

Part VI - Revalidation (To be filled by WORK EXECUTOR; CONTRACTOR ISSUING AUTHORITY) / VI Dio - Revalidacija (Ispunjava IZVODJAC
RADOVA; IZDAVATELJ
I am aware of the conditionsDZR)
described in this PTW, and I confirm that all the safety measures suggested in this PTW and other relevant documents will be strongly observed.
All personnel under my supervision will be instructed on the hazards in the work and safety measures to be taken for this activity. /
Upoznat sam sa uvjetima iz DZR i potvrdjujem da ce se sve preporucene zastitne mjere primijeniti i svi relevantni dokumenti detaljno pregledati.
Svi djelatnici
DATE / pod mojim nadzorom ce biti upoznati saFROM:
Time opasnostima na radu i primijentit zastitne mjere. Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:
Sign. CIA / Sign.WORK EXECUTOR
Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:
Sign. CIA / Sign.WORK EXECUTOR
Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:
Sign. CIA / Sign.WORK EXECUTOR
Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:
Sign. CIA / Sign.WORK EXECUTOR
Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:
Sign. CIA / Sign.WORK EXECUTOR
Potpis /
IZDAVATELJ Potpis IZVODJAC:
DATE / Time FROM: Time TO /
DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

DATE / Time FROM: Time TO /

DATUM: VRIJEDI OD: VRIJEDI DO:

Sign. CIA / Sign.WORK EXECUTOR

Potpis /
IZDAVATELJ Potpis IZVODJAC:

Part VII - Close out (To be filled by WORK EXECUTOR; CONTRACTOR ISSUING AUTHORITY; CONTRACTOR HSE PTW Coordinator) /
VII Dio - Zatvarnje DZR (Ispunjava IZVODJAC RADOVA; IZDAVATELJ DZR; HSE DZR Koordinator)

WORK EXECUTOR confirms that all works is completed and the work site is in clean safe condition. / Date / Time / Sign.
IZVODJAC RADOVA potvrdjuje da su radovi zavrseni te da je ostavljeno radno mjesto ocisceno i sigurno. Datum: Vrijeme: Potpis:

CONTRACTOR ISSUING AUTHORITY accepts completion as above and verifies clectrical isolation/
Date / Time / Sign.
disconnections certificates are signed off. /
IZDAVATELJ DZR prihvaca zatvaranje i provjerava zatvaranje elektricnog izolacijskog prikljucka. Datum: Vrijeme: Potpis:

CONTRACTOR HSE PTW Coordinator accepts completion as above and verifies close out of the
Date / Time / Sign.
permit /
Datum: Vrijeme: Potpis:
HSE DZR Koordinator revidira i prihvaca zatvaranje DZR