COLD WORK PERMIT Fire extinguisher N2 Purged / Steam Out System Mechanically Isolated

Erect signs and barriers Keep work site free of trip hazards Multi-Lock Isolated
Day Shoring Slope & Benching Eye Washer
Night
Permit Registry No.
Control the working hours Measure the temperature Comply with MSDS
NO WORK IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT SAFELY
Others : Water station
STOP WORK AND EVACUATE MUSTER POINT ON HEARING ANY EMERGENCY ALARM
5. PPE & SAFETY EQUIPMENT REQUIRED (by Performing Authority)
1. SPECIFICATION OF WORK (by Performing Authority)
Mandatory Fall Protection Eye & Face & Body Hand Protection Monitoring Equipment Respiratory Protector
Work Location : System (Item NO.) :
Safety Helmet Full Body Harness Face Shield Cotton Gloves H2S Badge Half Mask Respirator
Work Description :
Safety Shoes Fall Arrest Chemical Suit Leather Gloves Gas Monitor Full Face Respirator

Safety Glasses Hearing Protection Chemical Boot Lubber Gloves Film Badge/ Dosimeter Dust Mask
Equipment & Tools to be used :
Safety Gloves Ear Plug Rubber Boot Chemical Gloves Survey Meter Breathing Apparatus
Validity : This Permit is valid from DATE Hrs to DATE Hrs
Coverall Ear Muff Disposable Suit ETC. Life Jacket/ Vest
Company : Department : Apron Others :
6. GAS ANALYSIS OR INITIAL GAS TEST( by Authorized Gas Tester)
Requested by : Signed : ※ Task must be clearly described.
Not Required Inside Ouside Initial Result Authorized Gas Tester
2. HAZARDOUS ACTIVITIES / HAZARDS IDENTIFIED (by Performing Authority)
Oxygen (%) 20.0% ≦O2≦ 20.9% 20.0% ≦O2≦ 20.9% Name
Excavation Work Confined Space Lifting operation Live Equipment Radiography Combustible(%) LEL ≦ 1 % LEL ≦ 10 % Signature
Toxic/H2S H2S ≦ 10 PPM H2S ≦ 10 PPM Date
Testing Maintenance Marine Work Diving Work High Voltage
CO CO ≦ 50 PPM CO ≦ 50 PPM Time
Low Voltage Welding sparks Electrical Spark Hot materials Eqpmt causing sparks ※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. ※ Usable O2 CH4 H2S
※ Comments/Remarks : other sheet CO Other
Gases/fumes H2S Scaffolding Working at Height Severe/Adverse Weather
7. APPROVAL & ISSUE - This permit must be approved when the above precautions are implemented
Limited/poor lighting Moving machinery Pintch points Awkward Access/Egress Sharp edges
Step1. Reviewed by (Contractor Authorized representative)
Manual handling Vibration Electrocution Pressurized Hoses/Lines Unguarded Opening
Date : Time : Name : Signed :
Dust/ Powder Hazardous Substances Underground Utility Overhead Power Line Chemical
Step2. Reviewed by (HSE Authorized representative)
Extreme weather Flammable materials Explosives Noise Vehicle Traffic Date : Time : Name : Signed :

Danger of falling Dropped Object Tripping/Slipping Hazard MAN-BASKET OPERATION Handrail & Grating Removal Step3. Approved by (Approving Authority)
Date : Time : Name : Signed :
Others :
Step4. Accepted by (Subcontractor Task Supervisor / Site Manager)
3. SAFETY CHECK (by Performing Authority)
NA * - Not Applicable YES NO NA* I have read and understand the above conditions and precautions and declare that I accept responsibility for
A. Supplementary Requirements B. Site preparations carrying out work specified on this Permit, that no attempt will be made by myself or by the persons under my control to
carry out any other work, and that I will notify the Contractor engineer (HGU) upon completion/suspension of this work.
1 Risk Assessment is prepared
1 Excavation Certificate? Ref No.
2 Relevant workers are trained
2 Confined Space Entry Certificate? Ref No. - Safety Induction Date : Time : Name : Sgined :
- Adequate Safety Training
3 Lifting Certificate? Ref No.
3 Are all hazards clearly identified at site? 8. RE-VALIDATION (Complusory RE-VALIDATION of the work permit each shift - to continue work)
4 Radiography Certificate? Ref No. 4 All precaution in order to minimize risks
Subcontractor (Task
are taken at the site? Date Validity Time HSE Subcont In-charge HGU Site In-charge HSE HGU In-charge
5 Electrical Certificate? Ref No. Supervisor)
5 Hand tools & Power tools are inspected
Signature Signature Signature Signature
6 Electrical Isolation Certificate? Ref No. 6 Heay Equipment & Machinery are inspected

7 Process Isolation Certificate? Ref No. C. Adjacent work site precautions Signature Signature Signature Signature

1 Is notification given to safety about Signature Signature Signature Signature

8 Diving Certificate Ref No.
possible road blocks
Signature Signature Signature Signature
9 Grating Removal Certificate Ref No. 2 Has wind direction been considered
3 Is hazards from adjacent work taken into Signature Signature Signature Signature
10 Scaffolding Certificate Ref No.
consideration
Signature Signature Signature Signature
4 Is there any radio active hazard
5 Lock Out & Tag Out Signature Signature Signature Signature

4. PRECAUTION TO BE TAKEN (by Performing Authority) 9. PERMIT CLOSE-OUT ( CLOSURE ) - It must be registered by PTW Coordinator
Thoroughly ventilated Fire hose run out and pressurised Provided with suitable access and egress
Closed by(Subcontractor) Accepted by(HGU Authorized representative) Registered by(Permit Coordinator/HGU HSE)
Gas test required Fire resistance blanket/habitat erected Area free of flammable/combustible materials Date Time Date Time Date Time
Signed Signed Signed
Maintain radio contact Depressurised Grounding
Water flushed Secure loose objects Drained free of liquids
Cross-Referenced Documents : YES NO
Firewatcher present Containers for welding rods to be provided System Electrically Isolated ※ NOTE
Attached File : YES NO