PERMIT TO WORK APPLICATION FORM

IMPORTANT NOTE: THIS PERMIT IS VALID FOR 24 HOURS ONLY. THE PERMIT IS AUTOMATICALLY SUSPENDED WHENEVER ANNoEMERGENCY ALARM
Reference 010 IS ACTIVATED.
APREALA
WORK MUST STOP AND SITEMARINE
MADE SERVICES LTD PERMIT RETURNED TO SOURCE.
SAFE AND Issue No 10
1.Vessel’s Name: Date: Location: 6. GAS TEST CERTIFICATE ( Tick boxes Issue where
Date applicable ) 01/02/2021
* Permit No: Manual APPLICATION: HOT WORK
SAFETY MANAGEMENT ACTIVITIES FORMSCOLD WORK A. REQUIREMENT A GAS TEST IS Prepared REQUIRED HSENOT
Dept.REQUIRED
Work Description: B. The worksite is to be examined for: Approved By
Title PERMIT TO WORK Snr Fleet Manager
OXYGEN FLAMMABLE GAS H2S OTHERS
AS STATED.
C. FREQUENCY ( Frequency to be stipulated by Approval Signatory
A. DETAILS OF WORK HAZARDS ( Tick Boxes) Gas testing must be carried out at the beginning of each shift or working day Once every
hour(s)
Working at Heights Working over water Hot Work When work commences after a break of more than 120 minutes Continuous testing is required
Working in Unmanned D. RESULTS The worksite specified in section 1was examined as follows:
Entry Into Confined Space Others
Machinery Space
Handling Hazardous Substances Machinery Maintenance Date
Time
% LEL if
B. SOURCES OF IGNITION
applicable
% O2. if
Flame Cutting, Welding Welding Torch Igniters Chipping Sparks
applicable
Grit Blasting Explosives Others ppm
C. ADDITIONAL DOCUMENTS REQUIRED TO ACCOMPANY PERMIT TO WORK Examiner’s Name
Checklist as per SEMM attachment 7.5 for the box/boxes ticked in (A ) Signature
2.. ISOLATION (Tick Boxes) 7. PERMIT AUDIT : SUSPENSION / RE- VALIDATION
Personnel must endorse this section by signing to confirm that the conditions of work detailed in sections
Instrument Power Supply Mechanical Power Supply Electrical Isolation 1 to 4 and section 5 of this permit have not changed and still apply if permit is revalidated and /or
confirm work has been suspended and equipment made safe by “ Approval for work Signatory”
3. WORK PERMIT SPECIAL PRECAUTIONS( For ticked box give details eg no. of firewatchers, overrides ACTION Work Stopped Revalidate Work Work Stopped Revalidate Work Stopped
isolated, protected or removed)
Fire watchers must be in attendance at all times ( ) Trips and alarms to be overridden ( ) Date
Gas, Flame, and smoke detectors to be smoked or Time
Combustible materials removed or protected ( ) Applican
isolated ( )
t
Hazardous Drains or vents in vicinity to be isolated. Instruments, sensors and light fittings must be Sign
( ) protected ( )
Artificial ventilation must be provided at the Date
Other Actions to be taken
worksite
4. PROTECTIVE EQUIPMENT ( Tick Boxes) Approval Time
Coverall/Safety Helmets/Safety Footwear Safety Spectacles Sign
Goggles/ Face Master Date
Ear Muffs/Ear Plugs Hood/Helmet Gloves/Gauntlets
Visor
Work Vest/Life Time
Boots/ Chemical Gloves Safety Net Fire Blankets
Jacket
Dust/Gas Sign
Safety warning Signs Self Contained BA Wet Tarpaulin
Respirator
Foam Extt. Dry Powder Ext Reason
Safety harness and Lanyard Co2 Ext ( )
( ) ( ) Suspended
a. Unacceptable work conditions b. End of working Day/Shift c. Emergency Alarm Activated. d. Others
5. CLEARANCE APPROVAL 8. WORK COMPLETED ENDORSEMENT
A. AUTHORIZING SIGNATURE B. PERMT APPLICANT C.SHORE APPROVAL FOR A. PERMIT APPLICANT Master’s Declaration Master’s signature
(MASTER) I agree to carry out all the above WORK SIGNATORY I have stopped work. The area has
( THE TASK HAS
I declare that work may proceed Date: I declare that I have visited the been restored to a safe and
worksite and it is considered “ safe operational condition BEEN COMPLETED
to proceed “ with the work TO MY
specified. SATISFACTION AND
Sign Date: Sign Time: Sign Date: Sign Date: THE AREA IS NOW Date :
Name/rank CLEAR OF ALL RISKS
Name/Rank: Name/Rank: Name/Rank:
AND HAZARDS. )
Remarks: * vsl code / year / running number Example : RDF3/12/001 (same code to be
9. PERMIT DISTRIBUTION: A. ORIGINAL: Master B. COPY: Displayed at worksite
recorded in PTW register )