LEIGHTON JOHN HOLLAND JOINT VENTURE

Contract T208 Construction of Springleaf Station and Associated Tunnels for Thomson Line

PERMIT-TO-WORK RE-VALIDATION FORM

Company:

Types of Permit:  W.A.H  Hot-work Permit No:

 Lifting  Excavation Permit Start:

 Boring  Piling Permit Expiry:

 Others:

In-Charge of the Work

This permit is valid only for the period stated above. Conditions of issue must be complied with throughout the
duration of the work. This permit is void if site condition deviates from safe work procedures or statutory
requirements. This permit may be withdrawn at any time if non-compliance is observed by anyone. Permit
Requester are responsible for the copy of this permit and must produce it on request.

I fully understand the requirements of this permit to work. I accept it is my responsibilities to ensure that the
works carried out comply with the safe work procedures and statutory requirements at all time:

Requestor Re-validation Subcon’s PM/CM Re-validation

Signature Signature
(Name) Date Time (Name) Date Time

* Maximum 7 re-validation (total of 7 concurrent shifts/ days)

Verification & Endorsement by LJHJV Appointed Assessors:

I fully understand the requirements of this permit to work. I have inspected the above-stated location and
confirmed that the safety measures are in place and the said location is safe for work:

Verification Endorsement

Operation Staff Re-validation HSE Staff Re-validation

Signature Signature
(Name) Date Time (Name) Date Time

* Maximum 7 re-validation (total of 7 concurrent shifts/ days)

T208-H&S-FRM-129+Rev+01+PERMIT-TO-WORK RE-VALIDATION FORM