Owner : Work Package Code : Contractor :

Work Package :
Permit Number :
Date ____ :

HIGH RISK PERMIT TO WORK

Permit can be obtained from Project Manager (PM) / Project Engineer (PE) / Supervisor (SV)
This permit must be displayed prominently at the area where the general work is to be carried out and protected from being damaged. Damaged permit
shall be considered as invalid.
Permit Application - Completed by PTW Applicant/Site Supervisor
Date & Time of Work From: To:
Work Performed by
Location/Area (Pls. Attach sketch/drawing & highlight position)
Work Description
Safety Requirements to be complied by Applicant: “Tick for Yes” or “NA for Not Applicable”
Approved Risk Assessment, Safe Work Procedure Available Adequate edge protection provided - top rail/ mid rail/ toe boards erected

Relevant personnel briefed on Risk Assessment, Safe Work Slab, edge or floor opening covered or barricaded with warning sign to warn
Procedures control measures & Method Statement persons to keep away

PTW / Location Plan displayed at place of work Appropriate PPE are given and worn

Adequate safe means of Access/ egress provided. Ensuring Housekeeping done after every working day

Adequate lighting & ventilation provided at workplace & along Inspection after Inclement Weather – Safe to work
access/ egress

Provide energy isolation for safety environment or make sure List and map the lock-out/tag-out area or equipment
there is no energy left in the system
Provide safety equipment/tools according to the method Baricade the work area only for the relevant personnel
statement and already calibrated
Others: Approved Technical Drawing, Method of Statement, Change Request
This permit only applies to 7 working days in a week. No permit shall be use for more that 7 workings days weekly.
All work activities after 6pm are to apply Over Time and PTW extension forms with approval from Owner
Permit Check & Endorsed - Contractor Appointed PTW Applicant / Site Supervisor
Acknowledge work to be done Other instructions / comments:
Checked and confirmed location of intended work
Name: Signature: Date & Time:
Applicant/GC/DC Supervisor

Confirmation - Contractor Safety Supervisor / Coordinator

I have assessed the intended work area. I am satisfied with the safety provision and confirm that the operation is safe to be executed by the
applicant
Name: Signature: Date & Time:
Safety Supervisor / Coordinator

Confirmation - Contractor Appointed Project Manager Site In Charge

The above-mentioned work is: Approved / Not Approved
Contractor Project Manager / Site Name: Signature: Date & Time:
Manager
Verification by Mechanical Electrical Plumbing Coordinator
Name: Signature: Date & Time:
MEP Coordinator

Verification by Appointed Owner Field Supervisor

Structure Approved Not Approved Signature:
Architecture Approved Not Approved Signature:
Mechanical Electrical Plumbing Approved Not Approved Signature:
Verification by Appointed Owner Engineer
Name: Signature: Date & Time:
Owner Engineer

Verification by Appointed Owner Project Manager / Construction Manager

Owner Project Manager / Construction Name: Signature: Date & Time:
Manager
Verification by Appointed Owner MEP Design Manager
Name: Signature: Date & Time:
Owner MEP Design Manager

Note:
Owner : Work Package Code : Contractor :
Work Package :
Permit Number :
Date 2 _________ :

Daily Checklist to be completed by Contractor

Day: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Date:
Approved Risk Assessment, Safe Work
Procedure Available

Relevant personnel briefed on Risk

Assessment, Safe Work Procedures
control measures & Method
Statement

PTW / Location Plan displayed at place

of work
Adequate safe means of Access /
egress provided
Adequate lighting provided at
workplace & along access / egress
Adequate ventilation provided at
workplace & along access / egress

Adequate edge protection provided -

top rail / mid rail / toe boards erected

Slab, edge or floor opening covered or

barricaded with warning sign to warn
persons to keep away

Appropriate PPE are given and worn

Ensuring Housekeeping done after
every working day
Inspection after Inclement Weather -
Safe to work

Provide energy isolation for safety

environment or make sure there is no
energy left in the system

List and map the lock-out/tag-out area

or equipment

Provide safety equipment/tools

according to the method statement
and already calibrated

Baricade the work area only for the

relevant personnel
Others:

Checked by Contractor Applicant:

Checked by Contractor Safety:
Verified by MEP Coordinator:
Verified by Owner Supervisor:
Verified by Owner Engineer:
Safety Requirements to be complied by Applicant: “Tick for Yes” or “NA for Not Applicable”
Attached photocopy Daily Toolbox Meeting Attendance record.