Step 4 SRC PTW Coordinator

Cold Work Permit Review

Permit NO
00

Polaris Tower 3B+ G+3P+29TYP+H+CMECHL,

FLOOR Business Bay(Dubai) Date
PTW CO Sign
PTWDD
Step 1 Site Description
CONTRACTOR NAME: DATE :

AREA: Time:

DESCRIPTION OF TASK : SUPERVISOR IN-CHARGE:

CONTRACTOR RESPONSIBLE ENGINEER: SIGNATURE:

HSE OFFICER (CONTRACTOR) SIGNATURE:

Step 1 Task / Precaution Checklist (use below answer  / )

TOOLS HANDLING WORK WITH HAZARDOUS CHEMICALS
£ Inspect tools (color coded) £ Check chemical compatibility £ Toxic Substance
£ Tools in good conditions £ Corrosive Substance £ Flammable Substance
£ Tools with guards £ Seal sewers/others
£ Proper use of tirfor Ventilation required £ Natural £ Forced
£ Equipment turned off when unattended £ Special cleaning of equipment/pipelines
£ Machines in motion identified £ Spills precautions £ Dripping tray
£ Equipment checked before working and controlled Begins £ Material Safety Data Sheets
£ Continuous/Regular Gas Monitoring
GENERAL PRECAUTIONS
£ Hard Barricades £ Safety barricade tape
£ Suspend adjacent works £ Mechanical blocking
REQUIRED SUPPORTING DOCUMENTS
£ Adequate lighting £ Tripping hazards controlled
£ Proper access/egress available £ Watchers available £ Method Statement/Risk Assessment
£ Wet floor/area £ Protection screens £ P&ID’s
£ Radio/Mobile £ Welfare facilities £ Single Line Diagrams
£ Heat stress prevention £ Avoid pinch points £ Underground facilities Diagrams
£ Safe work with Forklifts/Mechanical move of materials £ Proper Cable £ Layouts
management £ Electrical drawings
£ ELCB provided for each extension £ 3rd party inspection certificates
£ guard of the machine is good condition £ 3rd party training certificates
£ is the activity required a lone working ?, if yes, what control measure has been £ Government authorizations
established to protect an employee from lone working?
FIRE PRECAUTIONS
£ Proper extinguisher available £ Firefighting Assistance£ Covered drains
£ Pressurized firefighting hose ACCESS AND EGRESS
£ Close to naked flames, sparks from £ Is demarcated the access
£ Smoke £ Flame £ Heat £ inspection of access platform
£ Fire and gas system isolated adjacent works £ working inside of excavation
£ Fire resistant barriers £ Sparks free tools £ is the housekeeping standard is good
£ Explosion proof equipment required £ is the access and egress are free from damage.
£ Intrinsically safe equipment required
£ Fire water protection system online
£ Remove combustible materials

INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X)

□ Helmet □ Gas Mask □ Safety Gloves
□ Safety Shoe □ Rubber Safety Boots □ Safety Glasses
□ Safety Belts □ Safety Harness□ Dust Mask

Additional control measures established:

Is Electrical PTW required? Is Confined Space PTW required? Is any Hot work permit is required? Is any other PTW required?
YES __ NO___ YES ___ NO ___ YES ___ NO ___ YES ___ NO ___
PTW Number PTW Number PTW Number PTW Number
If yes, attach a Copy If yes, attach a Copy If yes, attach a Copy If yes, attach a Copy

The following environmental factors have been assessed and are suitable for the works:

Clear visibility / No
Weather / wind (Yes / No) sandstorms (Yes / No) slippery surface (Yes / No)

PERSONAL PROTECTIVE EQUIPMENT

Step 2 VERIFICATION BY SRC HSE IN CHARGE

 Step 4 SRC PTW Coordinator

Cold Work Permit Review

Permit NO
00

Polaris Tower 3B+ G+3P+29TYP+H+CMECHL,

FLOOR Business Bay(Dubai) Date
PTW CO Sign

Step 3 Approved by Issuing Authority

Duration: Valid From Valid To

Date : Time: Date: Time
THIS PTW IS APPLICABLE FOR:- DAY SHIFT NIGHT SHIFT

Step 3 Approval and Acceptance

Handover by ISSUING authority

The above work can Proceed, having discussed the hazards involved and the precautions required as specified on this Permit with the Responsible
Engineer.

Name Signature Date Time

Acceptance by Receiving Authority:

I confirm that I understand the work to be carried out, the hazards involved and precautions required as Specified on this
Certificate. I shall ensure that all personnel working on this Permit are made aware of these conditions via a Permit Signing Record. The Permit Signing
Record will be kept with the Field copy and Fully maintained by the Receiving Authority.

Name Signature Date Time

Eng/Sup
Contact Telephone Number：
Step 4 Handback and Cancellation

Hand back by Receiving Authority

I Confirm that Work is(delete as appropriate)
a) complete, ALL personnel have been removed from the work area and the work area has been left in a Safe Conditional)
b) not complete, ALL personnel have been removed from the work area and is in the following safe condition (specify)

Name Signature Date Time

Cancellation by PTW Coordinator PTW

I Confirm I understand the status of the task at hand back
Comments

Name Signature Date Time

DAILY RE-EVALUATION

START FINISH RECEIVING AUTHORITY HSE AUTHORITY

Comments
DATE TIME TIME Receiving Authority / Task Signature Area relevant Subcons Signature
Supervisor Name HSE officer