BINDER

Permit Ref No: DP / ARC /
REQUEST TO USE 220V POWER TOOL

REQUESTER
NAME STAFF ID NO. DEPT./Company LOCATION SIGN
CLUB
Mr. YOUSUF MEP HOUSE
Note:
1. I will arrange 30mA ELCB in between DB & the power tool separately.
2. Every usage I’ll ensure that machine, accessories and the extension wire is in good condition.
3. This permission letter will be present with all approved power tools.
4. I declare that once the validity for the usage of 220V gets completed, I will set the tool out of the Workplace.
REASON FOR 220V
TOOL DETAILS
S.NO Machine Id No Machine Name Make

1
DURATION
Start date: __________ End date: __________
Number of Days in word: _________
AUTHORIZED BY:
NAME DESIGNATION SIGNATURE

PROJECT: SAADIYAT INFRASTRUCTURE PUBLIC REALM AND LANDSCAPE WORKS PACKAGE 2 – BEACH AND MARINA DISTRICT
FORM NO.:
SHIFT HANDOVER FORM SHF / ARC /
Project: Date:
Location: Time:
Valid PTW Nos.:
General condition of Equipment.
Ongoing activities.
Major PTW Activities expected during shift.
Sub-Contractors on site and their activities.
Incidents/Accidents and new procedures to prevent recurrence.
Supervisors / Foremen walk round their area.
Supervisors/ Foremen hold a toolbox talk and record who attended, what was discussed
and any actions.
Information
Any planned work in his shift.
Communicated to
Oncoming Shift: Major safety critical equipment isolated or not operational.
Number of people on site and shift split.
VIP visits (expected – client etc.).
Any new standing instructions or revised/updated procedures.
Others……………………………………………………………………….
……………………………………………....................................................
……………………………………………………………………………….
Details /Comments:
Shift Handed over
By: (Outgoing Shift):
Name: ………………………………….. Signature: ……………………………………… Date: ………..……………………….
Details / Comments:
Shift Handed over
To: (Oncoming Shift)
Name: ………………………………….. Signature: ……………………………………… Date: ………..……………………….
NOTE: This form shall be used by CONTRACTOR if the Work Shift changes within the validity period of open Permit to Work (PTW).
CONFINED SPACE ENTRY CHECK LIST

LOCATION:
SUPERVISOR RESPONSIBLE FOR WORK:
PERMIT NO: (ATTACHED) ISSUE DATE: EXPIRY DATE:
DESCRIPTION OF WORK:
EQUIPMENT / MATERIALS TO BE USED INSIDE CONFINED SPACE:
WATCHER’S NAME:
YES NO YES NO
TRAINED METHOD STATEMENT / COSHHE / MSDS
LOG SHEET EMERGENCY HOOTER / PHONE
PERSONNEL PERMITTED ENTRY

Trained Trained
NAME NAME
YES NO YES NO
ATMOSPHERE MONITORING
DATE TIME OXYGEN % COMBUSTIBLE GAS % TESTERS SIGNATURE
OXYGEN LEVEL – MIN. 19.5%, MAX. 23.5% COMBUSTIBLE GAS – MAX 5% L.E.L
PRE-ENTRY CHECKLIST YES NO N/A
All access ways secured in an open position?

Adequate supply of fresh air available for the duration of entry?
Adequate access and egress provided to access ways/entrances?

Is oxy/acetylene equipment required?
(If yes – complete additional requirements information listed below)
Is welding required in the confined space?
(If yes – complete additional requirement information listed below)
Has gas testing been completed? Are levels satisfactory?
Have entry and emergency instructions been given to entrants and watcher?
Has the type of adjacent works been considered?
Have combustible materials been removed from the area?
Are fire extinguishers required to be located at access locations?
Are ladders required for internal access?
(If yes – complete additional requirements information listed below)
Are combustion engines a minimum of five (5) metres from ventilation
openings?
Are all pipelines, electrical sources, etc. isolated, tagged and witnessed?
Is the type of work being done is likely to cause hazard. e.g. Fume
Is mechanical ventilation required?
Are personal monitors required to be used by entrants?
Additional Requirements/Special Conditions?
Completed By (Signature) Name (Print) Position Date

Entry / Exit Log
TIME
TIME IN NAME SIGNATURE SIGNATURE
OUT
PTW AUDIT CHECKLIST

Hot Work
Permit Number: Permit Type:
Cold Work
Project
Permit Validity:
/Location:
Actual Work
description:
Job Performer: Permit Issuer:

(Name and (Name &
Designation) Designation)
Objective - To determine that the Permit To Work process is being delivered at an operational level. Measured outcome will be
distribution and completion of associated documentation in the correct sequence, in the right location and to an acceptable level of
quality and safety. Closure of works must be regarded with the same sense of priority. All documentation must be assessed for
completeness and accuracy.
Note: Select a percentage of the open Permits in circulation on the day of the visit. In the instance that there are none, conduct a
completed Permit audit based on information attained and recorded from some previously recorded completions.
1. Work Specification: Yes No N/A Remarks
Is the location and area for work correctly identified ?
Is the work description is clear and specific ?
Clearly identified possible hazards for the activity requiring permit ?
2. Documentation:
2.1 Does the work permit contain the following documents ? (as applicable) Yes No N/A Remarks
Method Statement
Risk Assessment
Services Drawings
Logistics & Traffic Management Plan / Layout
Lifting Plan
Fire Prevention Plan
Shift Handover Form
2.2 Required Supportive Permits are identified and approval available ? Yes No N/A Remarks
Isolation Confirmation Permit
Confined Space Entry Permit
Lifting Permit
Excavation Permit
SIMOPS / Interface Permit
Work at Height Permit
Others.....
PCD-QSC-FMT-49 / Rev.00 / 15 July 2018

PTW AUDIT CHECKLIST

3. Trainings and Competency: Yes No N/A Remarks
Job Performer Competency ?
Permit Issuing Authority Competency ?
4. Permit Conditions: (Validation / Revalidation) Yes No N/A Remarks

Permit timeframe not exceed twelve (12) hours or one (01) work shift
whichever is lesser i.e. only valid for one shift (12 hours) ?
If extension:
The timeframe extended maximum for six (06) days for same shift timing
(in total one week including issue date) for the work to extend beyond the
stated finish time. PTW being revalidated (including re-approval from the
person issuing the permit) ?
COMPANY separate approval for Night shift or Work on Holidays
(weekend/public holidays) ?
Permit covers only one (01) work activity ?
5. Controls: Yes No N/A Remarks

Based on work activity and possible hazards the control measures are
identified ?
Controls measures are implemented effectively ?
6. Issue and Closeout of Permit: Yes No N/A Remarks
Declaration by Job Performer (Name and signature) ?
Authorization by Permit issuer (Name and signature) ?
Permit Closeout properly after completion of Work and ensuring the area
is returned to clean and in a safe condition ?
7. Recordkeeping: Yes No N/A Remarks
Permit Log maintained and available ?
Records maintained till the completion of project or at least one year

whichever is more ?
8. Concerns Raised during Audit: Action By Target Date Remarks
9. Audit Team:
Auditor Name: Designation: Signature: Date:
PCD-QSC-FMT-49 / Rev.00 / 15 July 2018

PERMIT TO WORK / CERTIFICATE LOG
DATE OF
PERMIT / CERTIFICATE TYPE ID No. ISSUED AUTHORITY JOB PERFORMER DATE OF ISSUE
CANCELLATION
CONFINED SPACE ENTRY PERMIT PERMIT NO.: CSEP / ARC /
SECTION I TO BE FILLED BY JOB PERFORMER (Originator) - CONTRACTOR

Project /Location: Attachments:
Method Statement:
Work description: Risk Assessment:
Possible Hazards: Others:
SECTION II PERMIT VALIDATIONS

From: From: Other Permits or activities in the area that could interfere: (if so specify)
Date: Time :
To: To:
SECTION III CONTROLS: TO BE FILLED BY ISSUING AUTHORITY (Advice can be sought from HSE Engineer)
 for YES and X for No Yes NA  for YES and X for No Yes NA
Adequate Ventilation; Drains, sewers and
01. Are the competent persons assigned for the job? 09.
manholes purged etc.
Area of work clean and safe including adjacent Continuous Gas Monitoring Specify (O2,
02. 10.
ones with Suitable access or Egress. H2S, toxic gases etc.) & recording.
Unused materials/ equipment removed from Adequate illumination, flame proof /
03. 11.
location. intrinsically safe lighting.
Area barricaded with appropriate signs showing COSHH assessment recorded (as
04. 12.
safe limit at work location. applicable)
Emergency & Rescue arrangements
Standby person to prevent access to confined
05. 13. (Tripod, Shutdown clear & known, Alarm,
space area.
Fire Extinguisher..............)
Job Specific PPE other than mandatory
System of communication in place, System for
06. 14. PPE (Safety Harness, Cartridges Masks,
monitoring e.g. personnel in/out log
Breathing Apparatus, Others ......................)
Tools and equipment checked for safe use / valid
07. 15. Others..........................................................
certifications
08. Job Safety Analysis (JSA) 16. Others...........................................................
Others Actions & Precautions: Atmospheric Testing
Factors Min Max Result Time Remarks
%LEL N/A 5%
%O2 19.5% 21.8%
CO N/A 30mg
H2S N/A 10ppm
PERMIT APPROVAL (TO BE FILLED BY
DECLARATION BY CONTRACTOR SECTION IV
ISSUING AUTHORITY)
I understand and accept responsibility for the work and ensure Work shall be carried out ONLY after complying with the
comply with these stated conditions. I have checked the location precautions given in Section – III of this Permit. I declare that
and all concerned has been briefed about the emergency all precautions have been taken & are safe to conduct work.
procedure and a Toolbox Talk to ALL involved in the activity. NAME: SIGNATURE:
Job Performer Name: Signature: HSE Officer: Signature:
` REVALIDATION If required (maximum for 06 days with valid supporting certificate - if any)
Date Job Performer (Contractor) HSE Officer (Contractor) Issuing Authority
CLOSE OUT (Work has been completed, the area is returned to clean and in a safe condition - work area
SECTION VI
checked for signs of fire, continuously for minimum one hour after completion of hot work)
JOB PERFORMER SIGNATURE : ISSUING AUTHORITY SIGNATURE:
DATE : TIME : DATE: TIME:
Note: Original Permit must be at job location along with applicable Permit and the copy must be submitted to HSE Department. The Permit should be applied at least 24 hours
before applying for Permit to Work to start the activity.

EXCAVATION PERMIT PERMIT NO.: EP / ARC /

Method Statement:
Services Drawing:
Date: Time :
To: To:
Are the competent Persons / Operators assigned
01. 09. Job Safety Analysis (JSA).
for the job?
Area of work clean and safe including adjacent Excavation side protection (Benching,
02. 10.
ones with suitable Access and Egress. Shoring and/or Sloping).
Excavated material cleared from edges,
Area barricaded with appropriate warning signs
03. 11. Unused materials/ equipment removed from
showing safe limit at work location.
location.
Trial pits for allocating underground services, use
04. 12. Adequate Ventilation & illumination.
of cable detectors etc.
Existing services protected (underground, on/above Continuous Gas Monitoring Specify (O2,
05. 13.
ground). H2S, toxic gases etc.) & recording.
Emergency & Rescue arrangements
Existing services isolated (underground, on/above
06. 14. (Alarm, Fire
ground)
Extinguisher..............................)
System for monitoring e.g. Inspection checklist,
07. 15. PPE (Cartridges Masks, Breathing
..................................................................................
Apparatus, Others ......................................)
Tools and equipment checked for safe use / valid
08. 16. Others...........................................................
certifications.
Others Actions & Precautions: Atmospheric Testing (if required)
%LEL N/A 5%
%O2 19.5% 21.8%
CO N/A 30mg
H2S N/A 10ppm
ISSUING AUTHORITY)
Job Performer
HSE Officer: Signature
Name: Signature:
SECTION V REVALIDATION If required (maximum for 06 days with valid supporting certificate - if any)
SECTION VI

SIMOPS / INTRFACE PERMIT PERMIT NO.: SIMP / ARC /

Method Statement:
Logistics plan:

Date: Time :
To: To:
 for YES and X for No Yes N A  for YES and X for No Yes NA
Both Parties aware of the interference of their Knowledge of all utilities / services passing
01. activity. Hazards, risk and control measures 08. in the working zone (drawings, trial pits,
communicated to both parties through Toolbox talk. cable detectors)
Both Work Parties' Supervisors coordinated and Emergency arrangements: ..........................
02. 09.
properly communicated about the activity. ....................................................................)
Security arrangements: Provision of controlled Are the competent persons assigned for the
03. 10.
access provided with watchmen. job?
Provision of logistics arrangements, traffic diversion
Provision of electrical power supply (shared
04. equipment (cones, barriers, warning tape, signs / 11.
or independent)
flashers) Maintenance of logistics roads.
Safe means of access/egress. Public Protection
PPE (Hi-Visibility vest, Full Body Harness
05. (Pedestrian passage-way, signage, overhead 12.
with double lanyard, Helmet with Chin strap
protection)
....................................................................)
Exclusive work zone with barricades and Wastes management (housekeeping
06. 13.
appropriate warning signs, Watchman provision. responsibility).
Welfare arrangements provided on site. (Toilets,
07. 14. Reinstatement of area for getting clearance
Drinking water, Rest shelters etc.)
Others Actions & Precautions: PERMIT APPROVAL (TO BE FILLED BY
SECTION IV
ISSUING AUTHORITY)
Work shall be carried out ONLY after complying with the
conditions given in Section – III of this Permit.
NAME: SIGNATURE:
DECLARATION BY SECOND PARTY REQUESTING FOR DECLARATION BY FIRST PARTY CONTROLLING THE
WORK IN FIRST PARTY CONTROLLED AREA WORK AREA
I understand and accept responsibility for the work and ensure I communicated and handed-over all requirements and
comply with these stated conditions. I have checked the location conditions to requested party.
and all concerned has been briefed about the emergency
procedure and a Toolbox Talk to ALL involved in the activity. Name: Signature:
SECTION V
JOB PERFORMER SIGNATURE: (2nd Party) FIRST PARTY SIGNATURE:
FINAL CLOSING OUT BY ISSUING AUTHORITY: TIME: DATE: SIGN:
Note: Original Permit must be at job location along with applicable Permit and the copy must be submitted to HSE Department. The
Permit should be applied at least 24 hours before applying for Permit to Work to start the activity.
ISOLATION COFIRMATION PERMIT PERMIT NO.: ICP / ARC /

Method Statement:
Others:
Possible Hazards:
Other Permits or activities in the area that could interfere: (if so specify)
From: From:
Date: Time :
To: To:
01. Are the competent persons assigned for the job? 08. Job Safety Analysis (JSA).
Exclusive zone with barricades and appropriate Emergency arrangements: ..........................
02. 09.
warning signs, Watchman provision. ....................................................................)
Prevention of exposure to nearby hazards
Electrical Equipment Isolated, Earthed, De-
03. 10. (electrical cables / panels, water, pressure
energized.................................................................)
lines, ..........................................................).
Considerations for external factors (Wind
Mechanical Equipment Isolated, Depressurized,
04. 11. speed, illumination, rain, dust,
Gas freed, ...............................................................)
...................................................................).
Lock out / Tag out requirements completed (by Continuous Gas Monitoring Specify (O2,
05. 12.
Competent authorized person). H2S, toxic gases etc.) & recording.
06. Unused materials removed. 13. PPE (Hi-Visibility vest, Rubber Gloves,
....................................................................)
Safe means of access/egress, adequate
07. 14. Others ..........................................................
illumination.
Others Actions & Precautions: Lock out / Tag out
Factors Duration Start Time Sign Open Time Sign
Lock ID
Tag ID

ISSUING AUTHORITY)
procedure and a Toolbox Talk to ALL involved in the activity. Name: Signature:
SECTION VI
Note: Original Permit must be at job location along with applicable Permit and the copy must be submitted to HSE Department. The
Permit should be applied at least 24 hours before applying for Permit to Work to start the activity.
PERMIT NO.: LP/ ARC /
LIFTING PERMIT
Attachments:
Project /Location:
Method Statement:
Lifting Plan:
Date: Time :
To: To:
01 Are the competent Lifting Supervisor, Operator and
08. Unused materials/ equipment removed.
. Riggers assigned for the job?
02
Valid Lifting Equipment & Accessories Permits. 09. Crane Operator's daily inspection.
.
03 Exclusive zone with barricades and appropriate Emergency & Rescue arrangements (Fire
10.
. warning signs, Flagmen provision. Extinguisher.................................................)
04 Ground conditions suitable for the weight of crane
11. PPE (Hi-Visibility vests, ............................
. and load being lifted, area away from excavation.
....................................................................)
05 Existing services protected (on/above ground, safe
12. Job Safety Analysis (JSA).
. clearance from overhead electrical cables).
06
Considerations for Wind Speed & illumination. 13. Others...........................................................
.
......................................................................
Agreed means of communication e.g., Hand
07 ......................................................................
Signals, Radio. (Tower Crane: Cab 35m above
. ......................................................................
ground - mandatory radio communication).
......................................................................
Others Actions & Precautions: Atmospheric Conditions
38km/h
Wind N/A
(20.5 knots)
01 Foot- candle
10 Foot-
Lighting N/A approx= 10.764
Candles lux
ISSUING AUTHORITY)
Job Performer Name: Signature:
HSE Officer: Signature:
SECTION V
JOB PERFORMER SIGNATURE: ISSUING AUTHORITY SIGNATURE:
LOCKOUT/TAGOUT LOG SHEET PERMIT NO.: ICP / ARC /
INITIATED RELEASED
S.N. EQUIPMENT DESCRIPTION
OPERATION MAINTENANCE DATE TIME BY OPERATION MAINTENANCE DATE TIME BY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
LOCKOUT/TAGOUT LOG SHEET PERMIT NO.: ICP / ARC /
INITIATED RELEASED
S.N. EQUIPMENT DESCRIPTION
OPERATION MAINTENANCE DATE TIME BY OPERATION MAINTENANCE DATE TIME BY
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
PERMIT NO.:
CONCRETE PERMIT CP/ ARC /
THIS IS NOT AN ENGINEERING REPORT. THE FORMWORK AND FALSEWORK REQUIRED TO BE CHECKED BY COMPETENT ENGINEER OF CONTRACTOR AS PER APPROVED METHOD
STATEMENT. THIS PERMIT APPLICABLE FOR MAJOR CONCRETING AND CRITICAL WORK AREAS ONLY (HORIZONTAL & VERTICAL ELEMENTS)
PROJECT NAME
CONTRACTOR Al Ryum Cont. & Gen. Trans. LLC DATE: TIME:
SUB-CONTRACTOR: RESPONSIBLE ENGINEER

(INVOLVED IF ANY) (STATE NAME)
METHOD
LOCATION / AREA: APPROVAL STATUS
STATEMENT RISK ASSESSMENT
(AS PER APPROVED DRAWING) OF -MSRA
(ENCIRCLE THE
YES NO YES NO
CORRECT STATUS)
TICK ✓ THE APPROPRIATE BOXS
NOT APPLICABLE
UNACCEPTABLE
ACCEPTABLE
UNSAFE /
SI NO
CHECK ITEMS
REMARKS
01 AREA WITH REGARDS TO HOUSEKEEPING

02 ACCESS / EGRESS ARRANGEMENTS
03 WORK PLATFORM / SCAFFOLD CONDITION (REQUIRED TO
BE ERECTED BY COMPETENT SCAFFOLDER)
04 SCAFFOLD INSPECTION & TAG (REQUIRED TO BE
INSPECTED BY COMPETENT SCAFFOLDING SUPERVISOR)
05 EDGE PROTECTION OF WORK PLATFORM (APPLICABLE
FOR 1.5 M & ABOVE)
06 CONCRETE PUMP CONDITION/ EQUIPMENT LOCATION
(COMPACTED AND EVEN GROUND)
07 EQUIPMENTS CONDITION (PHYSICAL)
08 EQUIPMENTS CERTIFICATION STATUS
09 POWER TOOLS CONDITION/INSPECTED
10 ALL PROTRUDING REBAR PROTECTION/ SHARP EDGE
PROTECTION
11 ELECTRICAL DISTRIBUTION BOARDS CONDITION
12 POWER CABLE MANAGEMENT
13 ILLUINATION ADEQUACY
14 FIRE SAFETY PREVENTION
15 PERSONAL PROTECTIVE EQUIPMENTS
16 FLOOR OPENING PROTECTION
17 OVER HEAD PROTECTION
18 TRAFFIC MANAGEMENT
19 SPILL CONTROL MEASURES
20 CONCRETE WASH AREA
SIGNATURE OF CONTRACTOR HSE SIGNATURE OF CONTRACTOR CIVIL
MANAGER: ENGINEER / CM/ PM:
PRINT NAME
PRINT NAME
SIGNATURE OF COMPANY HSE
ENGINEER:
NOTE: ITEM 05 OF THE CHECKLIST IS APPLICABLE EVEN FOR LOWER HEIGHTS AREA, SHOULD THE HSE ENGINEER PERCEIVE RISK OF EMPLOYEES BY FALLING OR TRIPPING OVER
FROM WORK AREA, THE IDENTIFIED ISSUE MUST BE RECTIFIED IMMEDIATELY THIS RECORD IS TO BE SUBMITTED TO THE ADNOC HSE REPRESENTATIVE BEFORE CLEARANCE.
PCD-QSC-FMT-71/Rev. 00/06 MAY 2015 Page 1 of 1

PERMIT NO.: WAHP / ARC /
WORK AT HEIGHT PERMIT
Method Statement:
Fall Prevention Plan:
Other Permits or activities in the area that could interfere: (if so specify)
From: From:
Date: Time :
To: To:
01. Are the competent persons assigned for the job? 08. Unused materials removed.
Exclusive zone with barricades and appropriate Emergency Rescue arrangements: .............
02. 09.
warning signs, Watchman provision. ....................................................................)
Prevention of exposure to nearby hazards
Safe Working Platform as per specifications
03. 10. (overhead electrical cables, water,
(Inspected and tagged by Competent Inspector).
excavations, ..............................................).
Over 10 meter high scaffold with design drawing
04. 11. Job Safety Analysis (JSA).
calculation and approval.
Safe means of access/egress (Safe ladder Considerations for Environmental
05. installation & tagging, Ladders having 75 degrees 12. Conditions (Wind speed, illumination, rain,
(4:1) and 1.05 meter above platform). dust, ...........................................................).
Provision of Safety Net, Life line, Anchorage point
PPE (Hi-Visibility vest, Full Body Harness
06. (Installation, testing & tagging by Competent 13.
with double lanyard, Helmet with Chin strap
person)
....................................................................)
Public Protection (Pedestrian passage way,
07. 14. Others ..........................................................
signage....................................................................)
Others Actions & Precautions: Atmospheric Conditions
38km/h
Wind N/A
(20.5 knots)
10 Foot- 01 Foot- candle
Lighting Candles N/A approx= 10.764
lux

ISSUING AUTHORITY)
Job Performer Name: Signature:
HSE Officer: Signature:
SECTION V

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Permit Ref No: DP / ARC /

REQUEST TO USE 220V POWER TOOL

NAME STAFF ID NO. DEPT./Company LOCATION SIGN

REASON FOR 220V

S.NO Machine Id No Machine Name Make

Number of Days in word: _________

NAME DESIGNATION SIGNATURE

Valid PTW Nos.:

General condition of Equipment.

Major PTW Activities expected during shift.

Sub-Contractors on site and their activities.

Incidents/Accidents and new procedures to prevent recurrence.

Supervisors / Foremen walk round their area.

Number of people on site and shift split.

VIP visits (expected – client etc.).

Any new standing instructions or revised/updated procedures.

CONFINED SPACE ENTRY CHECK LIST

EQUIPMENT / MATERIALS TO BE USED INSIDE CONFINED SPACE:

PERSONNEL PERMITTED ENTRY

All access ways secured in an open position?

Adequate access and egress provided to access ways/entrances?

Additional Requirements/Special Conditions?

Completed By (Signature) Name (Print) Position Date

Entry / Exit Log

PTW AUDIT CHECKLIST

Job Performer: Permit Issuer:

1. Work Specification: Yes No N/A Remarks

Is the location and area for work correctly identified ?

Is the work description is clear and specific ?

Clearly identified possible hazards for the activity requiring permit ?

Logistics & Traffic Management Plan / Layout

Fire Prevention Plan

Shift Handover Form

Isolation Confirmation Permit

Confined Space Entry Permit

SIMOPS / Interface Permit

Work at Height Permit

PCD-QSC-FMT-49 / Rev.00 / 15 July 2018

PTW AUDIT CHECKLIST

Job Performer Competency ?

Permit Issuing Authority Competency ?

4. Permit Conditions: (Validation / Revalidation) Yes No N/A Remarks

Permit covers only one (01) work activity ?

5. Controls: Yes No N/A Remarks

Controls measures are implemented effectively ?

6. Issue and Closeout of Permit: Yes No N/A Remarks

Declaration by Job Performer (Name and signature) ?

Authorization by Permit issuer (Name and signature) ?

7. Recordkeeping: Yes No N/A Remarks

Permit Log maintained and available ?

Records maintained till the completion of project or at least one year

8. Concerns Raised during Audit: Action By Target Date Remarks

Auditor Name: Designation: Signature: Date:

PCD-QSC-FMT-49 / Rev.00 / 15 July 2018

PERMIT TO WORK / CERTIFICATE LOG

CONFINED SPACE ENTRY PERMIT PERMIT NO.: CSEP / ARC /

SECTION I TO BE FILLED BY JOB PERFORMER (Originator) - CONTRACTOR

Possible Hazards: Others:

SECTION II PERMIT VALIDATIONS

Job Performer Name: Signature: HSE Officer: Signature: