Western Marine Shipyard Ltd.

KOLAGAON,PATIYA, CHITTAGONG.

APPLICATION FOR PERMIT TO WORK

(WORK SHALL NOT COMMENCE UNTIL STAGE 1 TO STAGE 3 FOR CONTRACT JOBS IS DULT
COMPLETED AND ENDORSED BY THE RESPECTIVE PERSONNEL)

Permit no:
VESSEL NAME : DATE : COMMENCEMENT / /2015
TIME : HRS :
LOCATION OF WORK : COMPLETION DATE : / /2015
TIME : HRS :
TYPE OF WORK : WELDING/CUTTING/GOUGING/GRINGING/PREHEATING/PAINTING/AIR TESTING
DESCRIPTION OF WORK :

STAGE 1 : APPLICATION BY YARD FOREMAN / SUPERVISOR / ENGINEER.

The work area and its surrounding are free combustibles and flammables’.I shall also ensure that the following requirements
are met prior to commencement and during work SKETCH

Supply of sufficient forced ventilation and lighting.

NAME : ----------------------------------------------------SIGN-----------------------------

DEPARTMENT : -----------------------------------------------------------------------------

DATE: : ------------/-------- / 2015 TIME : …………………...HRS.----------.

STAGES 2 : ENDORSEMENT BY SAFETY ASST.OFFICER / OFFICER

I have inspected and confirm that

1.The work area and its surroundings are free of combustible/flammable materials.
2.The necessary safety requirements have been complied with.

Additional Safety precautions-------------------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Fit for work Not fit for work

NAME :----------------------------------------- SIGN : -------------------------------------------------

DATE : ------------------------------------------TIME: ---------------------------

STAGE 3: APPROVALS BY PROJECT MANAGER

1. I am satisfied that a thorough assessment of the work area and its surroundings have been made.
2. I am satisfied that all necessary safety measures have been taken.
I hereby approve the works.

NAME : --------------------------------------------------------- SIGN : ------------------------------------------

DATE : -------------------------------------- TIME : ------------------HRS---------------------------------------

 HS&E Record Revision: 00

CONFINED SPACE ETRRY PERMITE Revision Date:

Document Number: HS&E-F-4.4.6(am)

Date and Time Issued : Date and time Expires :

Job site/Location I D : Job supervisor :

Equipment to be worked on: Work to be performed :

Stand by Person name:

Atmospheric Checks Time : Oxygen %

Explosive % LFL
Toxic ppm
Tester’s signature :
Source isolation (no entry): NA Yes No
Pumps or pipe Lines blinded, disconnected, or blocked

Ventilation Modification: NA Yes No

Mechanical
Natural ventilation only

Atmospheric Checks after isolation and Ventilation Oxygen % > 19.5

Explosive %LFL < 10%
Toxic PPM < 10 PPM H(2)S
Time : Tester’s signature :
Communication procedures :
Rescue procedures :
Entry, standby, and back up persons : NA Yes No
Successfully completed required training ?
Is it current?

Equipment NA Yes No
Direct reading gas monitor tasted
Safety harnesses and lifelines for entry and standby persons

Hosting Equipment
Powered Communications
SCBA’s for entry and standby persons
Protective clothing
All electric equipment listed
Class1, Division 1 Group D and non sparking tools

Periodic atmospheric tests: Document has Register Oxygen % Time :

Oxygen % Time :
Oxygen % Time :
Explosive % Time :
Explosive % Time :
Toxic % Time :
Toxic % Time :
We have reviewed the work authorized by this permit and the information contained here in. Written instructions and safety procedures have been received and are
understood. Entry cannot be approved if any squares are marked in the “No “ column. This permit is not valid Unless all appropriate items are completed.
Permit prepared By:(supervisor) Approved By:(Unit supervisor) Reviewed By :(Cs Operations personnel )

Copies : Safety office

Unit Supervisor
 HS&E Record Revision: 00

HOTWORK PERMIT
Revision Date:
Document Number: HS&E-F-4.4.6(am)

GENERAL INFORMATION
Permit No.
Worksite identification: ………………………………………………… Hot work to be performed: …………………………………………..
Location/Building: ……………………………………….. Authorized Duration of Permit: Date: ……………….to……………….
Time: ………………….to …………………………….
SOURCE OF IGNITION
o Acetylene torch Electric tools Soldering
o Abrasive saw Heliarc welding Drilling
o Electric arc Propane Torch Other………………

SOURCE OF IGNGTION
THIS HOT WORK PERMIT NAY BE SIGNED AND HOT WORK AUTHORIZED ONLY AFTER SATISFACTORY COMPLIANCE WITH ALL
ITEMS
o Continuous monitoring of atmospheric o Floors swept clean of combustibles o Inert gas blanket required?
conditions maintained? o Welding, cutting, fume ventilation or respirator
o Checking for flammable/combustible gas and o Remaining combustible or flammable materials required?
oxygen levels? 10m horizontally as well as vertically from o Building/area air currents and outdoor wind
o Special danger, caution, warning signs posted? source of heat? direction known?
o Trenches over 1.5m deep shored or sloped? o Non-movable combustible or flammable o Hazardous material spill location equipment
o Oxygen-rich environment evaluated? materials isolated, covered/shielded with fire and countermeasures available?
o Fire watch provided during work and 30 retardant material ? o Supervisor notified work location and time of
minutes after completion of work? o Vertical and horizontal openings within 10m operation?
o Work areas and adjacent areas where sparks sealed or covered for spark or vapor control? o Involved personnel and contractor employees
may have spread checked out 30 minutes after o Heat transmission, conduction, radiation, notified of hazards?
work completed? controlled? o Means of egress identified and available?
o Vessels, equipment drained, purged, o Hazardous material transfers disconnected o Fire protection equipment available and
ventilated, and cleaned? within 21m of hot work? operational?
o Lockout/tag out of electrical, mechanical, o Automatic fire sprinkler system operational?
chemical, blanking, cap piping implemented?

APPROVALS AND AUTHORIZATIONS

This permit is valid as long as work conditions existing at the time of issuance continue. It expires on any change of
condition that adversely affects safety of the work area while work is in progress.

STOP WORK IMMEDIATELY IF PLANT EMERGENCY ALARM SIGNALS AN EMERGENC IN OR NEAR YOUR WORK AREA.
FOLLOW FIRE WATCH INSTRUCTIONS.

I have personally inspected the location where the above work is to be done .I have checked for compliance with the safety
precautions listed on the permit and authorized the work to be performed.
Title Printed Name Signature Date

Originator/Approver
Safety Officer
Welder
Fire Watch