FM-$H-001-1 Rell.

PT. GUNANUSA UTAMA FABRICATORS

Project: 2-tf.,1() ~ It~ 1, c
COLD WORK PERMIT Permit No. :~.I~ ICWP I.XL. J.1.!:i1

Date J Time issued

Work area (Include Elevation)
Equipment & Tools to be used
Description of works

Will the require coordination with other Subcontractors? Yes 0 No !!X If Yes state Subcont name and it activity following list

Name of foreman to be present during the job

Date: ~ H'O\J 3-0 IV

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Supervisor

WJSA is in place and socialized Yes iZf 17. Danger area demarcated Yes 0
Approved procedure is in place Yes 0 18. Safety sign installed Yes CIZl
Drawing is in place Yes IlZJ 19. Safetyman standby is required Yes 0
Heavy equipment and tools used is certified Yes 0 21. Standby blower, air circulation is required Yes 0
Operator is competent person Yes 0 22. Self Contained Breathing Apparatus Yes 0
Anti sparking tools is used Yes 0 23. Barricade area is required Yes fl2(
Wearing proper PPE Yes It2l 24. Is radio communication required Yes crzr
Equipment and tools are in good condition Yes IS2f 25. Is fife saving appliances required Yes 0
Hazard & precaution is explained to the workers YesD 26. Emergency rescue Kits standby is required Yes
Scaffolding Jladders has been inspected Yes0 37. Hand tools and equipment are calibrated Yes
Fun body hamesS/life lines has been provided Yes 0
Depressurized, drained, flush, purged Yes 0
Isolation equipment & lines Yes D
Explosslon proof electrical equipment Yes D
Earthing againts static electric Yes 0

necessary precaution if required (please state}

!;:::•• n",,,,j,,,,rJ'f"r.,,,,,,,.,,,n and Safety incharge on Site

Supervisor in charge 1 Subcontractor Supervisor :.

Name ,..,(It!o Signed

DJob not completed and to be continued Date _).8--,-/_H-,-I_20_n~_Time

..:-:
under Work Permit no..................... .
Give details: Safety In Charge
Name ItA ~ II) Signed

Date Time

Yellow Copy (Duplicate) : To be kept at Supervisor I Coordinator located at area

Blue Copy (Duplicate) : To be kept by PTW Coordinator.