LIFTING OPERATION 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 No N/A SECTION C: AUTHORIZATION

1 Has crane/lifting equipment been a certificate from the authority? 29 Permission hereby given to the bearer of this permit to carry
out the above mentioned work under the provisions
2 Has operator been the license from the authority? stipulated in this permit and in accordance with the Work
3 Cranes must be equipped with sound or light signals Permit System
4 Have barriers been positioned with warning signs?
5 Has a watchman been on duty at all times?
6 Has a crane hooks been with safety latch?
7 Has a load chart been available in the cab?
8 All lifting tools must be inspected before use
9 Adequate area for crane set - up outrigger fully extended Signature by: Contractor Site Managers / Executives
10 Outrigger Condition SECTION D: AUTHORIZATION
11 Hoist Ropes Drums (Rope not crossed or bird cage) 30 Permission hereby given to the bearer of this permit to carry
out the above mentioned work under the provisions
12 Rope Greased
stipulated in this permit and in accordance with the Work
13 Loose Lifting Tackle Permit System
14 Oil Seal Check
15 Hydraulic Pump Seal Check
Weight of load to be lifted must be accurately determined and
16 never guessed).
17 Awkward size / shape / sharp edges
18 Lifting of chemicals
19 Have rigging/lifting points on load? Signature of Haskoning' representative
20 Height to which load is to be raised? SECTION E: ACCEPTANCE
21 Safety fasten for a load 31 I understand the scope of work to be done and safety
precaution to be taken. I agree and accept all the provisions
22 Tag lines, Tugger lines
procedures and shall cease work should condition affecting
23 Is the route & laydown area clear of obstructions? safety aspect of the work changes
24 Is the landing area adequate size and load bearing ability?
25 Quality of foundations (soil compaction etc)
26 Clear communications
27 Adequate lighting
28 Have weather conditions been considered? Signature by: Performing Authority: Contractor supervisor
SECTION F: CLOSE OUT
32 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

Revision 00 HSE-13-Lifting Operation

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