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HOTWORK PERMIT

This permit must be displayed prominently at the work area


This permit is valid from (a.m/p.m) to (a.m/p.m) on the day of issued

SECTION A - WORK REQUEST


Contractor:
Location: Date: Time:
Specific Work Area:
Equipment to be worked on:
Description of work:

JSA No: N/A

SECTION B - CHECKLIST YES N/A SECTION C: AUTHORIZATION


1 Check area and equipment to be worked on 12 Permission hereby given to the bearer of this permit to carry out the
2 Flammable materials / LPG cylinder nearby above mentioned work under the provisions stipulated in this permit and
in accordance with the Work Permit System
3 Source of ignition nearby
4 Sufficient fire fighting equipment available
5 Equipment deenergized and system isolated
6 Circuit connected to equipment grounding
7 Shoring required for the walls during excavation Signature by: Contractor Site Managers / Executives
8 Special warning / barriers provided SECTION D: AUTHORIZATION
9 Standby supervisor identified 13 Permission hereby given to the bearer of this permit to carry out the
10 Protective equipment to be used: above mentioned work under the provisions stipulated in this permit and
in accordance with the Work Permit System
Rubber boots Hard Hat Hearing protection
Gloves Face Shields Safety Harness
Safety Shoes Safety Glasses

11 Additional Precautions to be taken: Signature of Haskoning' representative


SECTION E: ACCEPTANCE
14 I understand the scope of work to be done and safety precaution to be
taken. I agree and accept all the provisions procedures and shall cease
work should condition affecting safety aspect of the work changes

Signature by: Performing Authority: Contractor supervisor


SECTION F: CLOSE OUT
15 Completion/Cancellation
I certified that the above mentioned work has been completed
has not commenced
(Tick as appropriate) has commenced but is not complete

and that the work area has been left in a clean and safe condition (see remark)

Signed: Name: Time: Date:


(Performing Authority)
I declare that this permit is now withdrawn and cancelled.

Signed: Name: Time: Date:


(Approving Authority)

1st copy: Post At Job Site 2nd copy: keep to file 3rd copy: to SHE section

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