Form No: 1

3rd Floor Building F. Phoenix Sun Business Park

Libis, Quezon City
Application Date
Validity Period

WORK PERMIT FORM

2. PERMIT HOLDER INFORMATION
Permit holder Remar John Esteban Job Title Safety Officer
Company JO MAR BUILDERS Mobile No. 09560970518

3. WORK DESCRIPTION (Refer to JHA for details of work to be done, potential hazards and safety precautions)
Installatin of new Fire Pump Exact location ATEX Zone
(checked by permit issuer)
Tie-in new line from the new fire pump Fire Pump area

4. PRESENCE OF POTENTIAL HAZARDS

DANGER OF FALLING FLAMMABLE MATERIALS MOVING MACHINERY/EQUIPMENT SUBSTANCE HARMFUL TO HEALTH
ELECTRICULATION FLYING PARTICLES NAKED FLAMES/ARCS/SPARKS UNTRAINED PERSONNEL
EQUIPMENT GENERATING SPARK GAS UNDER PRESSURE OXYGEN DEFICIENCY/H2S UNFAVORABLE WEATHER
OTHERS:______________________

5. REQUIRED ATTACHMENTS
Clearance certificate is required if any of energy isolations is required:  Electricity hydraulic Pneumatic Mechanical Thermal Valve Chemical
Gas test certificate is required: once ____ hours
Job Hazard Analysis (JHA) Confined Space Entry Permit Excavation Permit Hot Work Permit
List of Contractor Employees Electrical Permit Heavy Lifting Permit Work at Height Permit

6. TOOLS AND EQUIPMENT (Checked by permit issuer)

Mobile Generator
Mobile Compressor

7. Chemical Products (MSDS checked by permit Issuer)

8. PERSONAL PROTECTIVE EQUIPMENT

CANVASS GLOVES EAR PLUGS GOOGLES LEATHER GLOVES SAFETY SHOES
COVERALLS FACE SHIELD HELMET (W/ CHIN STRAP) NITRILE GLOVES SELF-CONTAINED BREATHING
DUST MASK FULL BODY HARNESS IMPACT RESISTANT GLASSES RUBBER BOOTS APPARATUS
OTHERS:______________

9. WORKSITE SAFETY PRECAUTIONS

FIRE EXTINGUISHER: NUMBER______TYPE______CAPACITY______ FIRST AID KIT IS AREA CORDON OFF?
LIGHTING ROAD CLOSURE WARNING SIGNS

10. PERMIT APPROVAL

Permit Holder:
I will observe the above conditions and safety precautions for the abovementioned
work. I will instruct all personnel under my control accordingly.
Signature:_________________________________________
Name: _________________________________________
Date: _________________________________________
Permit Issuer:
I am aware of the work to be done and the precautions to be taken. Permission is
granted to the permit holder to perform the abovementioned work.
Signature:_________________________________________
Name: _________________________________________
Date: _________________________________________

11. DAILY APPROVAL BEFORE WORK COMMENCEMENT

DAY 1 2 3 4 5 6 7
DATE
TIME
NUMBER OF
WORKERS
PERMIT ISSUER

12. DAILY HANDOVER BETWEEN PERMIT ISSUERS

TIME
OUTGOING
PERMIT ISSUER
INCOMING
PERMIT ISSUER

13. DAILY WORKSITE CLOSURE

TIME
PERMIT HOLDER
PERMIT ISSUER

14. COMPLETION/TERMINATION OF WORK

Clearance certificate is checked. Permit holder Accepted by Permit Issuer
The worksite is in a clean and safe condition.
Job is completed. Signature:_________________________________ Signature:_________________________________
Give reasons if the job is incomplete: Name: __________________________________ Name: _________________________________
Date: __________________________________ Date: _________________________________

DATE WORK PERMIT NO.
PERMIT HOLDER MOBILE NO.
SIGNATURE: ________________
NAME:_____________________
WORK DESCRIPTION / SCOPE OF WORKS
Installation of new Fire Pump - TIE-IN
SPECIFIC WORK AREA
Fire Pump Area
PRIMARY OR SPECIAL HAZARDS
JOB STEPS
1. MOBILIZATION
2. Inspection and checklist of machine, power
tools and oxy acetylene to be used ( CHECKLIST)
3. Working area preparation and TIE-IN
preparation.
4. De-energized or shutdown the supply and
closing of gate valves of the old fire pump
machine.
5. Draining of water in the pipe line.
Doc No: LEV5 – FO03 WORK PERMIT AND SPECIAL PERMITS
Form No: 2
JOB HAZARD ANALYSIS
VALIDITY PERIOD CURRENT PAGE
CONTRACTOR COMPANY PERMIT ISSUER
JO MAR BUILDERS & ENGINEERING
SERVICES INC. SIGNATURE: _________________
NAME:______________________
EXISTING & POTENTIAL HAZARDS RECOMMENDED CORRECTIVE MEASURES
1.1. Lack of knowledge for the rules and 1.1a. Conduct Safety to ESI TM/TS or safety
regulation of new worker. Briefing (TOOL BOX TALK) before start any
activities.
1.1b. Complete PPE before entry to the ESI
premises.
1.2. Working w/o permits or unsigned permits. 1.2a. Making and approval of permits before start
of any activities inside the ESI premises.
1.2b. Personnel authorize to sign the permit shall
be responsible taking all precautionary measure
requires to prevent the danger of fire and
explosion and to assure the safety of the
personnel and equipment esp. the terminal plant.
1.2c. Make sure all the documents and
certifications needed is provided to ESI TM/TS for
them to approved or sign the permit.
1.2d. All concern personnel should given task to
coordinate each other for safety measures as a
given/instructed by; foreman/supervisor, terminal
representative and safety officer.
2.1. Defective and Malfunction 2.1a. Provide Checklist to inspected or evaluated
by terminal representative and safety officer.
2.1b. All Hand/Power tools, Cables, Machine, Oxy
Acetylene etc. should be inspect/check if it is in
good condition.
3.1. Uncoordinated works or scope of works 3.1a. Conduct Safety talk/Tool box Talk On-site.
3.1b. All workers should explained and
understand scope of work, to be given or
instructed by Supervisor, Terminal Representative
and Safety Officer.
3.2a. All personnel should wear Complete/Proper
3.2. Trip and Slip hazard PPE at all time.
3.2b. Prior to start the activity; clearing the
working are can help to eliminate Tripping
Hazard.
3.3a. Gast test the Area prior to start.
3.3. Combustible materials, atmosphere source of 3.3b. Standby fire extinguisher, standby fire hose
ignitions. connected to near hydrant area and set-up
temporary booth (COBOL) in the area.
3.4a. Put Signages or Barricade the area if
3.4. Un-authorized Personnel applicable.
3.5a. All personnel should organized all materials,
3.5. Un-organized Tools, Materials and tools and equipment to be used, to be led by the
Equipment to be uses. foreman.
4.1. Un-authorized personnel or lack of 4.1a. Authorized personnel should only perform
knowledge the said activities with supervision or guided by
the Foreman and Terminal representative.
5.1. Pressurized water 5.1a. Wear complete/proper PPE at all time
5.1b. Ensure that all gate valves are closed, apply

6. Cutting of pipes by using of GRINDER or OXY
ACCETELINE
7. Full out the equal tee and the cuted pipe
8. Install blind flanges at both end/side.
9. Re-start the old fire pump.
10. Take all removed pipe out of fire pump area to
be repair or fabricate ( bring all in Echo 4
temporary work shop)
11. Fabrication, Fitt-up flanges both ends of
removed pipes.
5.2. Watery/Wet area
6.1. Lack of knowledge or incompetent personnel.
6.2. Possible cause of fire and explosion due to
open flame cause by grinding and using oxy
acceteline.
6.3. Electrocution
6.4. Body injuries, cut and burns.
7.1. Human errror
7.2. Handling of materials and tools cause of
pinched.
8.1. Faillure of tight (bolts and nuts)
9.1. Un authorized personnel
10.1. Slip and trip hazard
10.2. Manual lifting
10.3. Pinched
11.1. Possible causes of fire due to open flame
cause by welding, cuttine and grinding.
11.2. Electrocution
11.3. Burns and Cuts
LOTO if applicable.
5.1c. Don’t go beyond or make distance in the
direction of the puff pressured water.
5.2a. Ensure that the water removed from the
pipe goes to the right disposal to prevent slips and
it us not the cause of electrocution.
5.2b make some way/solution for the work place
totally dry.
6.1a. Deploy competent/certified personnel
to perform the said activities.
6.2a. Ensure valid hot work permit before starting
any hot work activities.
6.2b. Gast test the work area before commencing
any hot work activities to ensure that there is no
flammable gases near the working area.
6.3c. Eliminate all possible causes of fire near the
working area.
6.3d. Deploy competent workers and fire watcher
equipped with complete fire fighting equipment
( fire extinguisher , fire hose ).
6.3e. Set up temporary booth (COBOL) to
eliminate spreading of sparks.
6.4a. Ensure that the working area is dry.
6.4b. Always check the condition of the cable and
power tools before using it.
6.4a. Wear complete/proper PPE at all time.
6.4b. Ensure machine guard of the grinder on
place or functioning.
7.1a. The leadman/foreman should instruct all the
workers the procedure of the said activities to
eliminate/avoid human errors.
7.2. Remove slowly the bots and nuts on the
flanges in both sides to avoid injuries or pinched.
8.1a. Do not substitute plier for wrench when
turning or tightening the bolts and nuts.
81b. Ensure that the bolts ant nuts are enough
tight before leaving and proceeding another step
of job to prevent leakage.
9.1a. Authorized personnel should only the one
who re-start the fire pump machine.
10.1a. Keep all scattered tools, materials used in
proper places, and clear the passage.
10.1b. All workers should spot tripping hazard and
have them removed before start travelling of said
material.
10.2a. The leadman/foreman should identify load
to be carried by workers. (max. load 25 kgs. /
person).
10.2b. Appl lifting technique, lift by leg not by
back.
10.2c. Workers need to be careful when carrying
any heavy objects.
10.3a. Wear complete/proper PPE at all time.
10.3b. Maintain good positioning, don’t cross your
legs or lie in any one position in long time.
10.3c. Avoid horse playing.
11.1a. Gas test the area before commencing any
hot work activities.
11.1b. Eliminate all possible causes of fire near
the working area
11.1c. Perform only the said activities inside the
temporary work shop to prevent/eliminate
spreading of sparks.
11.1d. Standby Fire extinguisher and fire hose
connected to near hydrant area.
11.2a. Check the condition of cable, wire of any
power tools to be used before using it.
11.3a. Wear complete/proper PPE at all time.
11.3b. Deploy competent/certified worker to

12. Hauling/travelling of fabricated materials
inside the fire pump area to be tie-in
13. TIE-IN operation flanges to flanges
14. House keeping
(Clean-up)
perform the said activities.
11.3c. Ensure the machine guard of the grinder on
place and functioning.
12.1. Slip and tripping hazard 12.1a. Keep all scattered tools and materials used
in proper places, and clear the passage.
12.1b. Workers should check any tripping hazard
and have them remove before start
travelling/haulling of any materials
12.2. Heavy lifting 12.2a. The leadman/foreman should identify to be
carried by workers (max. load 25 kgs./person).
12.2b.workers need to be carefull when
travelling/liffting of any heavy object.
12.3. Body injuries 12.3a. Wear complete/proper PPE at all time.
Pinched. 12.3b. Maintain good positioning, do not cross
your legs or lie in any one position for a long time.
12.3c. Avoid horse playing.
13.1. Un-coordinated and Un-organized work, 13.1a. Provide or explain the procedure to all
tools and equipment. personnel explained/instructed by the leadman
or foreman step by step.
13.1b. Organized all, all materials, tools and
equipment if what, when and how to be used.
13.2. Human Error 13.2a. Wear complete/proper PPE at all time.
13.2b. assess the work procedure before start the
work.
13.2c. Deploy competent worker on the given
activity.
13.3. Failure the stiffness/tight of the bolts and 13.3a. Donot substitute pliers for a wrench when
nuts cause of leackage. turning/tighten the bots and nuts.
13.3b. The leadman or foreman should double
check the said activities with the supervision of
terminal representative.
14.1. Slip and trip hazard 14.1a. Wear complete/proper PPE at all time.
14.1b. Clean the area w/o missing anything, once
the work is completed. Remove all the tools,
materials and equipment, remove garbage and
unwanted things in the area.
14.1c. assess all the remaining hazard and
associated risk to minimize/eliminate possible
incident may happen at the following days.
 Doc No: LEV5 – FO03 WORK PERMIT AND SPECIAL PERMITS
Form No: 3

LIST OF CONTRACTOR EMPLOYEES

WORK PERMIT NO. CONTRACTOR COMPANY VALIDITY PERIOD

PERMIT HOLDER GATE SECURITY GUARD PERMIT ISSUER

SIGNATURE: _________________ SIGNATURE: _________________ SIGNATURE: _________________

NAME:______________________ NAME:______________________ NAME:______________________

SERIAL NO. NAME IDENTITY CARD NO DESIGNATION SIGNATURE

REMAR JOHN ESTEBAN SAFETY OFFICER

WILFREDO HERMOSO FOREMAN SUPERVISOR

ARIEL ARENAL WELDER

DAN CYVIN DE LEON HELPER

ALEJANDRINO CUARESMA PAINTER

HENRY DELIT DRIVER

 Doc No: LEV5 – FO03 WORK PERMIT AND SPECIAL PERMITS
Form No: 11

Hot Work Permit

(In case of unfavorable weather condition, please cancel the permit!)
1. Control
Work Permit No. Hot work permit validity date
Work Permit Validity period Gas test certificate No.

2. Permit holder
Contractor Company JO MAR BUILDERS No. of contractor employees 6
Permit holder REMAR JOHN ESTEBAN Mobile No. 09560970518

3. Job description
Exact location of work FIRE PUMP AREA ATEX zone (validated by permit issuer)

INSTALLATION OF NEW FIRE PUMP, TIE-IN NEW FIRE PUMP LINE

4. Origin of flame/spark
drilling cutting (arc, oxygen, saw) welding lamp electrical equipment
 heating grinding oxyacetylene welding internal combustion engines
sand blasting camera arc welding impact works
others___________

5. Pre-job checklist
a. Persons have license/certificate for the particular work? Yes NA
b. Clearance required (e.g. mechanical, electrical, thermal, radioactive, pipe, valve, etc.)? Yes NA Use clearance certificate.
c. Fire safety equipment in place? (e.g. fire extinguisher) Yes NA
d. Flammable materials and products removed from the working area? Yes NA
e. No venting at the proximity? Yes NA
f. Protective screen in place? (flame-proof, spark-proof) Yes NA
g. Gas detector required? Yes NA If yes, once every _______ hours.
h. LPG sales/operation stopped? Yes NA
i. Restricted the access of unqualified persons from the worksite: Signs/tags Barricades Attendant: name/signature _________________

6. Periodic site inspections required once every _____hours

Time
Name
Signature

7. Permit approval
Permit holder Permit issuer
I have conducted joint pre-job site inspection. I have conducted joint pre-job site inspection.
I will stay at the worksite for continuous supervision. I will stay at the worksite for continuous supervision.
Signature: __________ Signature: __________
Name: __________ Name: __________
Date/Time: __________ Date/Time: __________

8. Completion/Termination
Job completed Status if job is incomplete Permit holder Permit issuer
Job incomplete Signature: __________ Signature: __________
Isolation is removed Name: __________ Name: __________
Worksite is clean and safe Date/Time: __________ Date/Time: __________