DAILY WORK PERMIT RESTRICTED AREA

REQUEST OFF 3RD RAIL

NO PERMIT / PERMIT NUMBER :

TANGGAL / DATE : April 2022
09
JAM KERJA / WORKING HOURS 10.00
CONTRACTOR / MANDOR APG /Sub PT CIP
AREA KERJA / WORK AREA :
Ushaped Span 0&7

JABATAN /
NO ID BADGE NAMA / NAME TYPE OF WORK
POSITION

1 Ivansyah HSE
2 Wanto SPV Pemasangan
3 Apri Spv Sub Expantion Join
4 Dedy Helper
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

OTORISASI IJIN / AUTHORIZATION PERMIT

ADHI KARYA RAILWAY SYSTEM CONSTRUCTION MANAGEMENT

Field Commander HSE Energizing SCC DPKA

Tanda Tangan / Signature

Nama / Name
Tanggal / Date

PENERIMA IJIN / RECIPIENT PERMIT

Supervisor Supervisor HSE

Tanda Tangan / Signature
Nama / Name Wanto Ivansyah
Tanggal/ Date 08 April 2022 08 April 2022
Notes : Permit harus disubmit setiap hari dan dimintakan tanda tangan satu hari sebelumnya.
Permits must be submitted every day and signed the day before.
Permit untuk disubmit paling lambat jam 16:00 setiap sore
Permit to be submitted no later than 16:00 every evening
Permit ini diperuntukkan untuk pekerja yang bekerja di area yang sudah bertegangan
This Permit is for workers who work in energize area
Wajib melampirkan Permit mingguan atau hand carry permit yang sudah diapprove
Must attach weekly Permit or hand carry permit that has been approved
 ALAT KERJA

Screwdriver
Hand drill
Cutter/Gunting

MANAGEMENT
izing SCC DPKA