REGISTRY NO :

WORK NIGHT
Supervisior ME Manager ME Safety & Health General Manager

PERMIT
PT. URBAN ASIA INDUSTRI

A. GENERAL INFORMATION
Time Requested :
Company Date
DD/MM/YYYY

Reference
Project Owner
HMMI project manager Work Permit (Refer to Work Permit) (Sign) (Sign) (Sign) (Sign)

Safety Watcher
Person in Charge(☎)
Contractor Project Manager by Owner Stand by Person (Name) (Name) (Name) (Name)

B. DESCRIPTION OF WORK
Detail of Work Potential Hazard
NO Location Risk & Hazard Control
(Specify only related work) and Risk Assessment
Hot Work :

Electrical Work :

Work at Height :

Machine Installation :

Others (Please Speicify):

C. WORKING TOOLS
NO General Working Tools and Equipment Condition Remark

D. SAFETY MANDATORY CONTROL FOR WORK AT NIGHT

Result
NO CRITICAL POINT
(Comply/Not Comply/Not Related)
1 A night lighting plan shall be developed to ensure that all activities and areas are adequately illuminated to perform work safety
2 Safety leader of worker must be fully designated during the implementatio of night work
3 All workers must use high-visibility apparel Involving in activities at night
4 Ensure all workers are aware of the dangers coming to and from work due to fatigue.
5 To split the work area, high visibility tape must be installed to notify other worker
6 Contractor is allowed to conduct their work if only this work permit is already approved with project owner and SHE PT.HMMI.
Additional Note :