WORK PERMIT CCSPC-WP-01

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PROJECT: CONTROL NO: _

LOCATION: DATE APPLIED:

POST THIS PERMIT AT THE WORK AREA

PERMIT HOLDER: DESIGNATION:

AREA/DEPARTMENT: CONTRACTOR:

TYPE OF WORK:

CONFINED SPACE EXCAVATION WORK HOT WORK ELECT’L/CHEM’L/MECH’L WORK

WORK AT HEIGHT LIFTING WORK OTHER

SPECIFIC WORK TO BE DONE: DATE OF WORK

FROM TO

SPECIFIC AREA OF WORK: TIME OF WORK

FROM TO

CHECKLIST OF REQUIRED DOCUMENT/S AND CERTIFICATE/S:

TRAFFIC MGT. CERT. GAS TEST CERTIFICATE SCAFFOLDING CERTIFICATE

LIFTING CERTIFICATE ELECTRICAL CERTIFICATE EXCAVATION CERTIFICATE
JOB HAZARD ANALYSIS (JHA) PRE-LIFT WORKSHEET LIFTING PLAN
SAFETY RISK ASSESSMENT EXCAVATION PLAN EMERGENCY PLAN

CHECKLIST OF WORKPLACE SAFETY PRECAUTION:

Ingress/Egress Fire Extinguisher/s Fire watch

Air intake/exhaust Lane Closure Road side protection

Warning Signs Lighting Barricade

LOTO Chem. Spill Containment Foreman/Leadman/Supervisor

Others:
 WORK PERMIT CCSPC-WP-01

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PERSONAL PROTECTIVE EQUIPMENT:

RAIN BOOTS WELDING APRON WELDING HOOD WELDING MASK SAFETY EYEGLASS (DARK) SAFETY SHOES (GEN)
DUST MASK LAB APRON/ SUIT WELDING BOOTS GLOVES (COTTON) SAFETY EYEGLASS (CLEAR) SAFETY SHOES (W/MIDSOLE)
EAR MUFF CHEM SUIT RAINCOAT GLOVES (LEATHER) HARD HAT SAFETY SHOES (W/ >14KV RATING)
EAR PLUG FACE SHIELD RESPIRATOR GLOVES (MAONG) HARD HAT (UP TO 600V) FBH w/ DOUBLE LANYARD
COVERALL LAB SHOES REFLECTORIZED VEST GLOVES (ELECTRICAL) HARD HAT W/ High Voltage Req't SAFETY BELT (Fall Restraint)
SCBA OTHERS

VALIDITY: (MAXIMUM OF 7 CALENDAR DAYS)

 This permit shall automatically revoked when an emergency alarm is activated and evacuation is in effect;
an accident in the permitted work area occurred; and/or non-existence of the designated Foreman, Lead-
man or Supervisor on the work area. SHE&S Focal Point shall issue Stop Work Authority.
 This permit should be reviewed and/or renewed if conditions in this permit change i.e. manpower, work
environment, tools, equipment and materials.

PERMIT CONFIRMATION AND APPROVAL PERMIT CLOSE-OUT

I have read and understand the
PERMIT safety requirements of this
_
HOLDER permit and will comply. SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

I will ensure full compliance

CCSPC PROJ. with all the requirements of
SUPV. this permit and will exercise _ _
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
full supervision of the work

I confirm that safety

EHS OFFICER requirements of this permit
_ _
are in place and endorsing its SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
approval.

I have personally checked and

PROJ. MGR approved the precautions and
conditions listed above and _ _
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
authorize commencement of
the work

NO FOREMAN/LEADMAN/SUPERVISOR - NO WORK!
WORK PERMIT REVALIDATION

DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

FOREMAN/LEADMAN/SUPVSR
EHS OFFICER
PROJECT MANAGER

cc: Original- Permit Holder (to be posted on

site) EHS Officer
Security Officer
 WORK PERMIT CCSPC-WP-01

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TRAFFIC MANAGEMENT CERTIFICATE

I have personally checked that the traffic management plan including installation of RECOMMENDED SAFETY MEASURES
safety barriers and road signs: O Use of lighting (type )
O has complied with the safe traffic requirement in preventing vehicle accident and O Use of PPE (type )
protection of the personnel working and within the vicinity of permitted area O Traffic re-routing
O may not be sufficient enough and shall be provided with additional precautions O Signages and barricades
O is not safe to perform assigned task O Standby Assistance (for rescue operation)
O
BY: NOTED BY: O

CONSTRUCTION/ELECT’L SUPV. / DATE PROJECT MANAGER / DATE

(Signature over Printed Name) (Signature over Printed Name)

SCAFFOLDING CERTIFICATE

Erected scaffolding was personally checked by me and certify that it is: RECOMMENDED SAFETY MEASURES
O Safe to use and perform specified job O Secure drop zone
O Safe to use and perform specified job following recommended safety measures O Use of FBH w/ double lanyard
O Not safe to perform specified job O Securely tied tools
O BP monitoring to personnel working @ ht.
O Daily inspection of scaffold
BY: NOTED BY: O Standby Assistance
O Rope, harnesses and/or wristlets
SCAFFOLD INSPECTOR / DATE PROJECT MANAGER / DATE O Others
(Signature over Printed Name) (Signature over Printed Name)

LIFTING CERTIFICATE

We conducted pre-use inspection
of our equipment, tools, and
materials to be use and certify
that:
O Safe lifting activity can be
done
O Safe lifting activity can only
be done following recommended
safety measures
O Lifting activity is not safe.
BY:
CRANE OPERATOR / RIGGER
(Signature over Printed Name)
I personally verified area of
lifting/ loading/ unloading and
certify that working environment
from ground to overhead is:
O Safe to perform lifting activity
O Safe to perform lifting activity
following recommended safety
measures
O Not safe to perform specified
job
BY:
PROJECT SUPERVISOR
Signature over Printed Name)
All required certificates
(operator, rigger & crane),
including JHA were submitted.
Alcohol test before lifting was
also done and I certify that:
O Safe lifting activity can be
done
O Safe lifting activity can only be
done following recommended
safety measures
O Lifting activity is not safe
BY:
EHS Officer
(Signature over Printed Name)
Pre-lift meeting was conducted
and Lifting plan was established.
After discussion with all
personnel concerned I certify
that:
O Safe lifting activity can be
done
O Safe lifting activity can be
done following recommended
safety measures
O Lifting activity is not safe
BY:
PROJECT MANAGER
(Signature over Printed Name)

RECOMMENDED SAFETY MEASURES

O O
O O
 WORK PERMIT CCSPC-WP-01

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ELECTRICAL CERTIFICATE

Machine, Tools, Equipment and/or / Facility was personally checked and tested by me RECOMMENDED SAFETY MEASURES
and certify that it is: O Isolate electrical energy using LOTO
O Safe to use and/or perform specified job O Isolate electrical energy using rubber insulator
O Safe to use and/or perform specified job following recommended safety measures O Use of multi-tester
O Not safe to perform specified job O Daily inspection of tools
O BP monitoring to personnel working @ ht.
BY: NOTED BY: O Buddy system
O Others
ELECTRICAL INSPECTOR / DATE PROJECT MANAGER / DATE O
(Signature over Printed Name) (Signature over Printed Name)

EXCAVATION CERTIFICATE

I have checked the site/studied the layout drawing and certify that the excavation: RECOMMENDED SAFETY MEASURES
O can be carried out without risk of damage to any underground services O Use of lighting (type )
O can be carried out provided that additional precautions are taken to prevent damage O Use of PPE (type )
to the equipment /services O Gas Testing
O is not safe to perform excavation O Shoring
BY: NOTED BY: O Signages and barricades
O Standby Assistance (for rescue operation)
CONSTRUCTION/ELECT’L SUPV. / DATE PROJECT MANAGER / DATE O
Signature over Printed Name) (Signature over Printed Name)