MKSP-KPN PROJECT

S URYA CIPTA KARAWANG

WORK PERMIT SYSTEM

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001/WPS/MKSP-KPN/22 0 Health Safety Environment Page 1 of 3

Date/ Tanggal :
PERMIT TO WORK Facility / Fasilitas :
Surat Izin Kerja No. of Work Permit :
❑ Hot Work ❑ Cold Work ❑ Energy ❑ Excavation ❑ Confined ❑ Critical Lift
Pekerjaan Pekerjaan Isolation Penggalian Space Pengangkatan
Panas Dingin Isolasi Bekerja Kritis
Energi Diruang
Terbatas
1. Description/location of job / Uraian / Lokasi Pekerjaan

No. of Worker / 2. Validity of Work Permit / Masa berlaku

Jumlah Pekerja Izin kerja
Work Permit Applicant /
Date / Tanggal :
Pemohon
From 08.00 Hrs To 17.00 Hrs
Sign / Tanda tangan
Work Permit Holder /
Pemegang Izin Kerja
Authorized Person / PenanggungJawab
Check if applicable and explain below
3. Isolations / Isolasi ❑ Electrical ❑ Mechanical Jika ada mohon dijelaskan dibawah ini
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………

Time and date isolated / Isolated by / Diisolasi Oleh: Position / Jabatan :

Jam danTanggal Isolasi:

………………………… ………………………………….. …………………………

4. Work Permit Requirement ❑ JSA & Risk Assessment ❑ Drawing Activity ❑ Rigging Plan
/ Persyaratan Izin Kerja
❑ Work Method ❑ As build Drawing ❑ Underground Composite

(Check the hazards and the required precautions / Beri tanda pada bahaya dan
5. Hazards
pencegahannya)

❑ Liquid/ gas under pressure / Cairan Gas ❑ Confined spaces / Di dalam ❑ Weather/ Cuaca ❑ Fire / Kebakaran
bertekanan Ruang Terbatas ❑ Electricity/ ❑ Toxins / Keracunan
❑ Explosion due to combustibles / Ledakan ❑ Danger of falling / Bahaya Kelistrikan
❑ Lifting Ops. /
dari material yang mudah terbakar Jatuh ❑ Corrosives / Korosi Pengangkatan
❑ 3rd party operations (explain below) / ❑ Moving machinery / ❑ Pinch points/ ❑ Scaffolding /
Aktifitas Kontraktor (Jelaskan dibawah) Peralatan / Mesin yang Terjepit Perancah
❑ Noise/ Kebisingan bergerak
❑ Flying particles or sparks/
Partikel terbang /Percikan
api
Other Hazards / BahayaLainnya
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………

Precautions: ❑ Airline (cascade) ❑ Water flushing ❑ Supervision ❑ Grounding

❑ Fire Extinguishers / ❑ Inert purging ❑ Stand-by-man ❑ Ventilation ❑ PPE
APAR
❑ H2S Monitoring ❑ Safety harness ❑ SCBA ❑ Barriers
❑ Job Safety Analysis
(JSA)
 MKSP-KPN PROJECT
S URYA CIPTA KARAWANG

WORK PERMIT SYSTEM

Doc No. REV.
001/WPS/MKSP-KPN/22 0 Health Safety Environment Page 2 of 3

Other precautions / Pencegahan lainnya:

………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………

6. Gas Testing / Pengetesan Gas

Oxygen / Oksigen H2S Flammable Gas / Gas mudah terbakar
Date Time Reading Date Time Reading Date Time Reading
Tanggal Jam Hasil Tanggal Jam Hasil Tanggal Jam Hasil

Gas Tester by / Pengetesan Gas dilakukan oleh :

Name / Nama : Sign / Tanda Tangan :

7. Work Permit Issued / Pengeluaran Surat Ijin Kerja 8. Authorization of Company (if required) / PenanggungJawab
The details of the permit have been discussed with the Permit Perusahaan (Jika diperlukan)
Holder and those involved / Surat ijin ini telah dibahas secara
rinci oleh Pemegang Ijin dan pihak -pihak yang terkait. Name / Nama :

Authorized Person / Penanggung Jawab _________________ Sign / Tanda tangan:

9. Issue and Acceptance / Pengeluaran dan Penerimaan Izin Kerja 10. Job Hand Over / Pengalihan Pekerjaan
I have checked the worksite and the required precautions have Permit Holder changed at /Perubahan Pemegang Izin pada
been taken and discussed with all involved / Saya telah
memeriksa area kerja dan pencegahan yang diperlukan dan telah …………………….…hours / jam ……………………….date / Tgl
dibahas oleh pihak-pihak terkait The in-coming Permit Holder and his workmen have been
satisfactorily briefed on all the hazards and precaution /
Pemegang ijin baru dan pekerjanya telah dijelaskan dengan rinci
tentang potensi Bahaya dan Pencegahannya

Outgoing Permit Holder / Pemegang Izin Lama :

-------------------------------------------------------------
Incoming Permit Holder / Pemegang Izin Baru :
Permit Holder / Pemegang Izin Kerja _________
---------------------------------------------------------------
11. De-Isolations /
Pelepasan Isolasi
❑ Electrical / ❑ Mechanical / 12. Suspension of Permit / PenundaanpenggunaanSuratIzinKerja
Elektrik Mekanik I declare that the work for which this permit was issued has been
The electrical/mechanical isolations applicable to the Permit have temporarily suspended, all involved have withdrawn and the
now been removed / Isolasi Eektrik/Mekanik yang dipakai dalam izin area/ equipment has been left in a clean and safe state/ Saya
ini telah dihentikan menyatakan bahwa Surat Izin Kerja yang telah diterbitkan ini ditunda
 MKSP-KPN PROJECT
S URYA CIPTA KARAWANG

WORK PERMIT SYSTEM

Doc No. REV.
001/WPS/MKSP-KPN/22 0 Health Safety Environment Page 3 of 3

Electrician / Ahli Listrik ......................................................... pemakaiannya sementara waktu, semua pihak yang terkait ditarik,
semua peralatan dan area kerja ditinggalkan dalam kondisi bersih dan
aman
Mechanic / Ahli Mekanik ......................................................... Reason of suspension / Alasan Penundaan :

Isolator / Di isolasi oleh .........................................................

Authorization Person / Penanggung Jawab :

12. Work Completion / Penyelesaian pekerjaan 13. Permit Closure / Penutupan Izin Kerja
The above work has been completed. The worksite has been The work has been inspected and is complete. The Isolation have
left safe, clean, and tidy / Pekerjaan diatas dinyatakan selesai. been removed and the area is safe / Pekerjaan diatas telah diperiksa
dan selesai. Isolasi telah dihilangkan dan lokasi kerja dinyatakan
Lokasi pekerjaan ditinggalkan dengan bersih, aman dan rapi
aman

………………………………..... …………………………
Authorized Person / Company (If Necessary) /
Permit Holder / Pemegang Izin Kerja ..................................... Penanggung Jawab Perusahaan jika perlu

Work Permit Extention Form / Form Perpanjangan Surat Izin Kerja

Sign
Date / Time / TandaTangan
No
Tanggal Jam MKSP MKSP KPN
HSE Supervisor Supervisor
08.00 –
1 17.00
08.00 –
2 17.00
08.00 –
3 17.00
08.00 –
4 17.00
08.00 –
5 17.00
08.00 –
6 17.00
08.00 –
7 18.00

Note :
Work Permit at any time may be revoked or reviewed if the performed does not
meet the requirements or provisions that safety required
Izin Kerja sewaktu-waktu dapat dicabut atau di tinjau ulang jika pekerjaan yang dilakukan
tidak memenuhi syarat atau ketentuan keselamatan yang disyaratkan