CONSTRUCTION PERMIT TO WORK Contractor Co.

Logo

(Part of OETC-HSE-O-COP-M-005, PTW Procedure)

PART 1- PTW APPLICATION PTW FORM NO:

Tender No Name of Company Start Date

Project Detail Department Finish Date

Type of Permit (Tick applicable)

Lifting Confined Space Hot Work Excavation

Working
Working at
Scaffolding / Ladder at Height Night Work
Height (OHL)
(MEWP)

1. 4.

Risk Assessment Attached 2. 5.

3. 6.

1.
Method Statement Attached
2.

Location Number of workers Equipment Involved

Brief Description of the work carried out

Basic Requirements / Hazards addressed (Tick mark whatever applicable)

First Aider Face / eye protection / Body Hard barriers / signage Water flushed
Apron
Fire warden Fall protection system Scaff Tag Oxygen percent
(Lanyard)
Fire Extinguisher / Fire Blanket Personal Fall Protection Electrical Isolation and Portable radio (walky talky)
(Full body Harness) locked
Emergency Vehicle Safety Shoes, Gloves, Mechanical Isolation Vented /Exhaust system
Coverall and locked
Advanced First Aider / Male Respirator Ventilation Fluid / Gas free
nurse
Safety Officer / Steward Ear Protection Light intensity Portable gas detector

Banks Man Hard Helmets with chin Static/Stable ground Taglines / Tools Bag / wrist wrap
strap for WAH
Buddy /Space watcher Vertical Lifeline Access / escape route Cable detector

Slipping / tripping Flying particles Wind velocity Poor Visibility

Fall from height Temperature / Humidity Poisonous gas / vapors Contacting energized lines

Caught between Heavy lifting Low oxygen Smoke/Dust / Fog

Falling objects High noise level Simultaneous operations Absence of Voltage

Name of PTW Applicant Date Signature

Revision – 0 01st July 2018 Documented Information # OETC-HSE-O-COP-F-015 Page 1 of 2

 CONSTRUCTION PERMIT TO WORK Contractor Co. Logo

(Part of OETC-HSE-O-COP-M-005, PTW Procedure)

PART 2- PERMIT HSE REVIEW

The risk assessment, Method statement and the precautions in PTW form are found satisfactory and forwarded to Contractor HSEO and
Consultant HSEO for further review

Name of PTW Issuer Date Signature

The risk assessment, Method statement and the precautions in PTW form are found satisfactory

Note: Reject if not satisfactory and send back to Applicant

Name of Contr. HSEO Date Signature

The risk assessment, Method statement and

the precautions in PTW form are found satisfactory

Note: Reject if not satisfactory and send back to Applicant

Name of Consultant HSEO Date Signature

PART 3- PERMIT ISUUE / PERMIT AUTHORIZATION

The Permit is authorized and issued

Name of PTW Issuer Date Signature

PART 4- PERMIT ACCEPTANCE AND RECEIPT

The Permit is accepted and all controls indicated in PTW Form, Method Statement and Risk Register shall be implemented

Name of PTW Receiver Date Signature

PART 5- PERMIT CANCELLATION

The Job is completed and all equipment demobilized and site is restored

Name of PTW Receiver Date Signature

Name of PTW Issuer Date Signature

Revision – 0 01st July 2018 Documented Information # OETC-HSE-O-COP-F-015 Page 2 of 2