HEALTH, SAFETY & ENVIRONMENTAL (HSE)

ELECTRICAL WORK PERMIT Form ID: NBHH-HSE-FM-005 Rev. No: 01 Date: 01-07-2024

AL HUDAYRIAT ISLAND PDA INFRASTRUCTURE - INFRA 3A & 3B ABU DHABI

JOINT JOB SITE INSPECTION IS REQUIRED WHEN ISSUING A PERMIT
Location: Permit No:
1. WORK DESCRIPTION BY ELECTRICAL ENGINEER
This permit-to-work (PTW) is to be retained by the Work In-Charge/Work performer while work is in progress and must be displayed in the working area. A copy of
this PTW must be retained by the issuing authority. After completion of job Return the signed, completed permit to Issuing Authority for the hand-back procedure.

Name: Job Title From: To:

Time
Duration
Company: Tel No:

Designation: From: To:

Signature Date
Location:

Work Description

Type of
Equipment
Description of
circuit equipment
2. CONDITION OF AREA AND ELECTRICAL WORK REQUIREMENTS
# ITEMS TO CHECKED YES NO N/A # ITEMS TO CHECKED YES NO N/A
01 Goal post provided with warning sign 12 Voltage-rated tools
02 Tool box / Task Talk (Hazards brief to the crew) 13 Suitable PPE for Task provided?
03 Assigned Competent supervisor (Attach Details) 14 Lock out Tag out
04 Is Emergency procedure established? 15 Heat / Cold Stress
05 Is method statement approved and available 16 Trained attendant (Attach Details)
06 Are Firefighting equipments available 17 Insulated tools & equipment provided
07 Restricted Boundaries & Warning Signs provided 18 Insulated Mats
08 Remove all jewels & metal apparel (i.e. belt buckle) 19 Portable Ladders
09 Drawing attached indicating the line to be energized 20 Rubber insulating equipment
10 Assigned Qualified workers (Attach Details) 21 Barricades
11 Suitable selection of non-conducting ladders- Fiber glass ladder or similar 22 Others:
3. PERMIT REQUEST (SITE ENGINEER)
Name of Work In-Charge: Nominated Work Performer Name:
I have personally viewed the area, assessed the hazards, and shall make sure that necessary precautions Designation: Date & Sign:
are implemented for this work. I nominated above mentioned foreman as work performer and have
made him and his team understood the requirements of this PTW and ensure their adherence to it.
4. PERMIT AUTHORIZATION (CONSTRUCTION MANAGER)
I, as an issuing authority declare that the above work has been discussed with the person(s) in charge of Designation: Date & Sign:
the work, the risk assessment / method statement has been reviewed and all safety precautions /
actions required are in place have been inspected by myself in accordance with this PTW requirements.
5. HSE VERIFICATION
HSE Comments/Recommendations: Name & Designation: Date & Sign:

6. REVALIDATION OF PTW
The maximum duration of this permit is 7 days, providing no change to the task or conditions has occurred.
The date, time on and time off must be completed and signed by the issuing authority and work in-charge to revalidate the permit.
Day – 2 Day – 3 Day – 4 Day – 5 Day – 6
Date
Time on & off
Sign – WI
Sign – HSE
7. WORK COMPLETION / CANCELLATION.
☐ All works Completed on this PTW, all persons, materials and equipment involved have been withdrawn and site left clean, tidy and safe.
☐ All works on this PTW has been suspended and PTW cancelled by HSE Responsible.

Name: Sign: EMP ID: Date & Time:

Authorized Person: Name & Designation: Date & Sign:
The work covered by this PTW is complete and the area has been left safe, clean, and tidy.

IN CASE OF EMERGENCY PLEASE CALL PROJECT EMERGENCY NUMBER - +971 50 728 8240
.