HEALTH, SAFETY & ENVIRONMENTAL (HSE)

CONFINED SPACE PERMIT Form ID: NBHH-HSE-FM-004 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. APPLICATION AND WORK DESCRIPTION BY SITE 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
Company: Tel No: Duration:
Designation: From: To:
Location: Signature: Date:

Work Description

Type of Confined Space.

2. CONDITION OF AREA AND CONFINED SPACE ENTRY REQUIREMENTS
S. No ITEMS TO CHECKED YES NO N/A S. No ITEMS TO CHECKED YES NO N/A
01 Full body harness and retrieval line, tripod, etc. provided. 11 Respirator required / type provided
02 Confined space area barricaded and signs provided 12 Confined space entrants are trained
03 Gas testing conducted by AGT & Recorded 13 Standby man/hole watcher assigned
04 LV lighting / illumination provided 14 Communication device
05 Airline / Breathing Apparatus 15 Safe access and egress provided
06 Is Emergency procedures and Rescue Plan established? 16 Air Circulation / Movers
07 Fire watcher assigned (Attached Details) 17 Protective Clothing
08 Is any Hot work performing inside CS? & PTW in place? 18 Entry & exit log provided (Attached)
09 Lifelines or retractable fall arrestor provided 19 Toxic Gas / Vapor
10 Are all entrants medically fit to enter into confined space? 20 Other:
3. AUTHORIZE GAS TESTER (AGT) DETAILS

Name: EMP ID AGT Training Validity Dt. SIGN

4. HOLE WATCHER DETAILS

Name: EMP ID TRAINING VALIDITY Dt. SIGN

5. 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.
6. 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.
7. HSE VERIFICATION
HSE Comments/Recommendations: Name & Designation: Date & Sign:

8. 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 Day – 7
Date
Time on & off
Sign – WI
Sign – HSE
9. 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
 HEALTH, SAFETY & ENVIRONMENTAL (HSE)
CONFINED SPACE GAS TESTING & ENTRY/EXIT LOG Form ID: NBHH-HSE-FM-004-A Rev. No: 01 Date: 01-07-2024

THIS FORM IS AN ATTACHMENT TO CONFINED SPACE PERMIT. Date:

Validation for ☐DAY 01 ☐DAY 02 ☐DAY 03 ☐DAY 04 ☐DAY 05 ☐DAY 06 ☐DAY 07
Permit Details Permit No: Permit Issue Date:

HOLE WATCHER Name: EMP ID: TPC VALIDITY:

GAS TESTING
AGT DETAILS: NAME: UAE ID AGT ID

GAS DETECTOR DETAILS: SERIAL NO CALIBRATION Dt. EXPIRY Dt:

Flammable Flammable
O2 Conc. (%) H2S (PPM) AGT O2 Conc. (%) H2S (PPM) AGT
# TIME Gases (%LEL) # TIME Gases (%LEL)
(19.5% to 23.5%) (<10 PPM) Sign (19.5% to 23.5%) (<10 PPM) Sign
(<5%) (<5%)

01 07
02 08
03 09
04 10
05 11
06 12
CONFINED SPACE ENTRANTS - ENTRY / EXIT LOG
CS ENTRANT 01 CS ENTRANT 02 CS ENTRANT 03 CS ENTRANT 04
EMP ID: CS Training Card: EMP ID: CS Training Card: EMP ID: CS Training Card: EMP ID: CS Training Card:
☐ YES ☐NO ☐ YES ☐NO ☐ YES ☐NO ☐ YES ☐NO
Name: Name: Name: Name:
TIME IN Sign TIME OUT Sign TIME IN Sign TIME OUT Sign TIME IN Sign TIME OUT Sign TIME IN Sign TIME OUT Sign

CS ENTRANT 05 CS ENTRANT 06 CS ENTRANT 07 CS ENTRANT 08

EMP ID: CS Training Card: EMP ID: CS Training Card: EMP ID: CS Training Card: EMP ID: CS Training Card:
☐ YES ☐NO ☐ YES ☐NO ☐ YES ☐NO ☐ YES ☐NO

Name: Name: Name: Name:

TIME IN Sign TIME OUT Sign TIME IN Sign TIME OUT Sign TIME IN Sign TIME OUT Sign TIME IN Sign TIME OUT Sign