Permit Number :

HOT WORK PERMIT

Step 1 By Permit Holder / Site Description

M/S No: CONTRACTOR NAME: Nama Kontraktor

TYPE OF WORK :Jenis Pekerjaan HOT WORK LOCATION : Jenis Pekerjaan

□ Arc Welding □ Grinding □ Brazing/Soldering □ Other Hot Work (specify)

□ Plasma cutting □ Tig Welding □ Cutting

DESCRIPTION OF THE WORK TO BE PERFORMED : Jelaskan pekerjaan yang dilakukan:

PLANNED STARTING DATE : Terkait dengan permit lainnya: PLANNED COMPLETION DATE :Rencana Tanggal Selesai

SUPERVISOR INCHARGE: Supervisor yang bertanggung jawab DATE/ Tanggal :

CONTACT NUMBER: Nomor kontak : SIGNATURE: Tanda Tangan:

THIS PERMIT IS NO VALID UNLESS ALL APPROPRIATE FIELDS ARE COMPLETED/

Permit tidak berlaku kecuali bidang yang sesua sudah dielngkapi

REQUIRED PERSONAL PROTECTIVE EQUIPMENT

□ No additional PPE
Helmet, Safety Shoes, Vest, Gloves. Long sleeve, long pants and mask always required

□ Special Gloves ( welding, hor or chemical

□ Face Shield/ Goggle for welding □ Particular Respirator
etc)

□ Welding Helmet/ Helm Las □ Fall Protection (Lifeline, safety harness) □ Gas/ Vapor respirators

□ Hearing Protection/ Pelindung Telinga □ Welding Cap □ Welding air purifying respirator

PRECAUTIONS CHECKLIST / DAFTAR PENCEGAHAN

□ Avalaible Emergency vehicle, communication item, and fire □ Personal Protective Equipment in good fit, maintain and repair/Alat
extinguisher, fire blanket and water bucket pelindung diri dalam keadaan baik, terjaga dan terawat

□ Flammable liquid , dust and oil deposite removed/ bahan mudah □ Firewatch is supplied with suitable fire extinguisher/ Penjaga api telah
meledak sudah dihilangkan siaga dengan APAR yang cocok

□ Explosive atmosphere in area limited / Bahan mudah meledak □ Fire watch is trained in use of this equipment and in sounding alarm/
sudah dihilangkan Penjaga api sudah dilatih dalam menggunakan peralatan dan membunyikan
alarm

□ Combustible on other side of wall moved away / Bahan mudah □ Confine space entry permit required/ Izin masuk ruangan terbatas
terbakar dipermukaan dinding tanah telah dipindahkan
 Permit Number :
HOT WORK PERMIT

Step 2. Contractor Area Engineer / Supervisor & HSE Manager

Approved by Name Signature Date

GS E&C Area Engineer

Manager

GS E&C HSE Manager (

Deputy)

Step 3. Review and Approve

Approved by Name Signature Date

GS E&C Project Manager

Step 4. Daily Inspection at Worksite Date Date Date Date Date Date Date
Signature Signature Signature Signature Signature Signature Signature

Sub- Con Site Manager/ HSE or Delegate

GS E&C Person incharge

Step 5 Permit Close/ Penutupan Permit

□Job Complete □ Job Incomplete

I have checked and workplace and clearing that I withdraw all my workforces from the area and it is safe
Saya telah memeriksa area kerja dan menyatakan bahwa saya telah menarik semua pekerja saya dari lokasi kerja dan aman
Permit holder/ HSE Team Name and Signature