PICO PLAY PTE LTD

DATE
NO.5223 KAMPUNG JERAM BATU
81500 PEKAN NENAS TIME WORKS to
PONTIAN JOHOR MALAYSIA
TELEPHONE: 07 699 1093
PERMIT TO WORK
Apply for:

Hot work Electric Isolation/High Voltage

Confined Space Entry Working at Height (above 3 metres eg. Roof)
Construction
Others (Please Specify): _______________________________________
SECTION 1: FILL UP BY PERSON IN CHARGES OF PROJECT/PERMIT ISSUE (PICO STAFF) (*Please attach copy of IC/Certificate of the contractor/invoice)
Person Issuing Permit-To-Work (LJE Staff):

Contact Number: Department:

Contractor/Employee Received Permit-To-Work:

Contact Number: Position:

Total workers involved: Location (Specify Area:

Description of work Hazard and Risk Assessment of Work Task

HAZARD RISK
1. 1.
2. 2.
3. 3.
SECTION 2: COMPULSARY SHALL BE CHECKED AND FILLED UP BY PERMIT ISSUE/PIC (LJE STAFF)
Hot Work/Welding/Grinding Working At Height ( Above 3 meter) Construction
Hot work supervisor Safety harness/lifeline, Safety helmet/Shoes Hearing protection (eg Ear Plug)

Face shield/Goggle/Safety Glass Scaffolding/Mobile Elevating Work Platform Appropriate respiratory/Dust Mask

Fire extinguisher Ladder/Stepladder in good working order Safety Glass/Safety helmet

Protection cloth/Safety jacket Competent person top inspect scaffolding > 3 Crane with valid permit
stacks (more than 18 ft)
Area free from Combustible Crane permit Dust extractor
Materials
Guardrails No chemical spillage allowed

Electrical Isolation/High voltage Confined Space Entry Compulsory PPE

LOTO system/electrical glove Certified Entry Person Safety Helmet

Insulated tool (blanket, footwear) Standby person Safety Shoes

Insulated Tool ( Blanket, Footwear) Authorised Gas Tester Safety Vest

Safety Glass/Goggle Safety Harness/Lifeline Safety Glove

Escape set

SECTION 3: ACCEPTANCE OF REQUIREMENT BY PERMIT ISSUER AND CONTRACTOR/EMPLOYEE

I have checked the requirement and equipment to be worked on and I am to ensure all I have been briefed on PTW requirement by Permit Issuer and will ensure all the
related requirements are strictly used. I am responsible for any unsafe condition and is requirements are strictly followed during the duration of work for the Environment,
given authorization to stop the work Safety and Health of people involved and protection of the environment. Our company
and I are fully responsible if any accident occur toward our workers during the period of
works
Permit issue/staff (PICO)
Contractor/Employee
NAME: NAME:

DATE: DATE:

SECTION 4: PERMIT APPROVAL SECTION 5: WORK COMPLETION DECLARATION

I have inspected the work area and believe to I have counter checked the work area
the best of my knowledge that the work has and believed that the work area left in
Management Representative HSE been completed safely and the work area left a safe conditions
in a safe state

Name: Name:
Contractor/Employee Permit issue/staff (PICO)
Name: Name:
Date: Date:
Date: Date:
Time: Time:
Remarks: The validity of this permit to work is seven (7) days