(HSE/dept/year/month/number)

REGISTRY NO : (HSE/UAI/2022/07/08)
PERMIT TO WORK PT.URBAN ASIA
SPV Mekanik Manager Mekanik Safety & Health General Manager
INDUSTRI
PT. URBAN ASIA INDUSTRI

A. GENERAL INFORMATION
Main Contractor
Company Name
Name

Project Owner
Date
(PT.UAI) (☎)
(Name & Phone Number) (DD/MM/YYYY 00:00 - DD/MM/YYYY 00:00) (Sign) (Sign) (Sign) (Sign)

Person in
Duration (Days)
Gusti Ramadhan Nurrohman Hendri Anur Awal Prayoga
Charge(☎) Type of Permit New Extend
(Name & Phone Number)

B. DESCRIPTION OF WORK
Shop Location
Project Name
Specific Area

Hot Work Electrical Work Civil Work Machine Installation Chemical Handling
Type of Work
Work at Height Confined Space Excavation Work Lifting Work _____________________________

High Risk Medium Risk Low Risk

Work Classification
*Please see attachment to determine
Rank A Rank B Rank C
the rank *If Rank "A", please fulfill "General A Rank Safety Control"

Safety Supervisor (______) Engineer (______) General Worker (______)

Total Worker
Specification of Worker
Involve
Specialist (______)* Supervisor (______) __________________ (______)

*Please specify and attach certified license for specialist worker (ex. Rigger, Welder, Heavy Equipment Driver, Eletrical expert, etc.)
C. WORKING TOOLS
List of Working Tools :

Ladders Bending Machine Wire Rope Scissor Lift Forklift _____________________

Chain Sling Self-Propelled Lift Backhoe _____________________

Scaffolding Air Compressor

Welding Machine Hand Drill Chain Block Truck Mounted Lift Exhaust / Blower _____________________

Circular Saw Electrical Cable Crane Gas Detector _____________________

High Speed Cutter

Oxy Cutter Drill Machine Electrical Panel Excavator Portable Generator _____________________

D. DOCUMENT LIST
I. MANDATORY DOCUMENT (S) : II. OPTIONAL DOCUMENT(S) : <based on classification of work, and requirement from owner>

• One Time Submission Equipment Inspection Checklist Temporary Facility

Pre-Qualification Work Agreement Organization Structure
Certification of Equipment (SIA) Design / Drawing
Master Schedule Work Procedures (SOP) Emergency Response Plan
License of Specialist Worker (SIO) _________________________________
• Periodical Submission
PPE Specification List _________________________________
Worker List Working Tool List
Material Safety Data Sheet _________________________________

General A Rank Safety Control

Good (√), Poor (X) (work after improvement)
Install pipe blanking or blinding, clean container,
PPE (safety helmet, safety shoes, Full body harness)
ventilation
Common Prepare equipment for communication, extinguishment,
Wear safety supervisor tag
rescue, explosion proof)
Safety Confined Space
Measures Safety training Respiratory equipment (for work / for rescue)
Check & record concentration of oxygen and gas (before
Post plans for safe work
entry)
Assign personnel to control vehicles when occupying a
Remove combustible materials & hazardous materials
road
Install fire blanket Check safety devices for transport apparatus
Hot Work Locate fire fighting equipment (3 fire extinguishers, fire
Heavy Material
Check signs for mutual communication of workers
hydrant)
Assign a fire watcher for hot work Install signage to prohibit access during using equipment
Check whether active electric line or non-active electric
Check the securing condition of ladder / scaffolding
line
Install lifeline to secure safety belt Shut off electricity and attach tag
Working at
Prohibit to move MEWP (Mobile Elevating Work
Electricity
Height PPE for insulation (e.g. insulation gloves)
Platform) when workers are on the platform
Baricade around the working area Prohibit active electric line work