Permit To Work REF: SHSE-ICT-PTW

Rev: 2021/01
Application Form

SECTION 1: (Please fill below required Applicant’s information)

Building Name Unit Number

Applicant Name: Applicant’s Company Name:

Applicant’s Contact Number: Subcontractor (if Nay)

SECTION 2: (Please Select one from below list. Note that one application form is valid for one type work activity only)
 Fit Out Works  General Maintenance  Pest Control
 HOT Works  Confined Space Works  Work at Height
 Event Setup  Other
SECTION 3: (Please fill below required permit to work information)
PTW Start Date: PTW End Date:

PTW Start Time: PTW End Time:

Complete Description of Activity:

SECTION 4: (Please provide the below required documents)

 Undertaking Letter/NOC  Risk Assessment & Method of Statement  Trade License
 Valid Emirates ID Copy  Relevant Local Authority Approval  Workers/Crew Name list

SECTION 5: (Safety and Security Precautions)

 PPEs revenant to the activity  Compliance to OSHAD requirement  Edge protection
 Safety Harness  Compliance to authorities’ requirements  Safety Helmet
 Work at height Certificate  Fire Extinguishers  Lock out/Tag out
 Other (if any)
SECTION 6: (Terms & Conditions and additional requirement)
Please read and acknowledge terms & condition and additional requirements of this permit, written on page 2 (Section 10)

SECTION 7: (Applicant Undertaking)

By signing this document, I am confirming that permit conditions and all safety precaution/HSE standards will adhere to all the
times, and I take full responsibility for carrying out and supervising the mentioned activities at ICT property. I have read and
acknowledged Section-10 of this permit. I will be liable for any ICT property Damages incurred, legal consequences, or insurance
claims resulted due to our working activities or workers' activities. I will be accountable for the wellbeing of myself and my crew
members/invitees/guests/workers while at ICT premises.

PERMIT APPLICANT: Name: Sign/Stamp: Date & Time:

SECTION 8: (ICT MANAGEMENT Approval)

ICT Property Management Name: Sign: Date & Time:

ICT Facility Management Name: Sign: Date & Time:

ICT HSE & Security Name: Sign: Date & Time:

ICT Marketing Department Name: Sign: Date & Time:

SECTION 09: (ICT Site FM Contractor’s Supervision Acknowledgment)

I hereby acknowledged that I have reviewed the above mentioned information and specification of work . All works will be
monitored and supervised according to ICT FM guidelines. Any HSE violation or deviation noticed will be reported to ICT FM.

Site Engineer/Supervisor Name: Sign/Stamp: Date & Time:

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 Permit To Work REF: SHSE-ICT-PTW
Rev: 2021/01
Application Form

SECTION 10: (Permit Terms & Conditions & Additional Requirement)

General terms and Condition
i) Any changes in the scope of activities, or failure to follow the conditions of the permit, will automatically invalidate the permit.
ii) Where work is suspended for any reason, the permit will automatically become void and a new permit will be needed to continue the works.
iii) Area to be made clear after completion of work; any leftover debris/material by the applicant/contractor will be disposed to ADM approved
location by ICT contractors and removal cost will be back charged to the permit holder/organizer..
iv) Permit Holder to strictly follow the approved time frame and apply for renewal before the expiry date of permit.
v) Noisy works are not allowed on Fridays, public Holidays and from 1700Hrs till 0800Hrs, or during hours specified by ICT Management. Permit
Holder shall agree on noisy works schedule with ICT management at the time of permit approval.
vi) It is applicant/contractor responsibility to obtain all local authorities required approvals and comply with OSHAD regulations/COPs
vii) It is applicant responsibility to hire licensed Security personnel/Safety Professional for necessary safety and security of work site, attendees/crew
member(s)/workers and subcontractors (if any). Applicant shall ensure necessary barricading of work site as per ICT guidelines/approval.
viii) Site Pre & Post inspection will be conducted by ICT site team. ICT and its representative deserve the right to inspect the work site at any time.
ix) For any shutdown/Fire Fighting System isolation the applicant must obtain ICT Facilities Management approval before commencement.
x) All Incidents /near Miss shall be reported to Security. Follow site emergency procedure in case of evacuation, using nearest exit.
xi) Applicant shall submit their complete PTW with all supporting documents to ICT 48 hours prior to commencement of work (Sunday to Thursday
8am-2pm only) On Fridays, Saturdays, or public holidays PTW application will not be accepted
Additional Requirement for HOT Works
• It is applicant responsibility to assign a competent person to inspect the site before commencement of hot works and assure that all
precautions have been taken to prevent fire in accordance with NFPA 51B and UAE Fire and Life Safety code of Practice.
• Sprinklers should be in service where provided.
• Specialist cutting and welding equipment must be from an approved supplier to the contractor.
• Assign a trained Fireman with Fire Extinguisher for Fire Watch during the activity and one hour after the Hot Works activity
• Provide appropriate PPE as per local and international HSE standards
Hot working within 10 meter of other work activities
• Floors must be swept clean of combustibles.
• Floors made from, or covered with, combustible material must be made wet, covered with damp sand, metal or other safety shield.
• No combustible material or flammable liquids should be within the 10m distance.
• Combustible and flammable liquids must be protected with covers, guards or metal shields.
• All wall and floor openings must be blocked off or covered.
Working on walls or ceilings
• Combustible material must be moved away from opposite side of walls and ceilings to reduce the risk of ignition through conduction.
• Work on enclosed equipment such as Tanks, Ducts, Dust Collectors, etc…
• The vessel or container must be prepared and cleaned of all combustibles and purged of flammable vapors with attestation/certification.
Additional Requirement for Confined Space Works
Pre-Entry Atmospheric Test
Substance(acceptable entry conditions) Measurement results Date & Time Comments
Oxygen(19.5-23.5%)
Flammable Gases (Lessthan10%LFL)
Hydrogen Sulfide (Lessthan10ppm)
Carbon Monoxide (Lessthan35ppm)
Other Gases
Ventilation (Specify the type of ventilation):
Atmospheric Test after Ventilation
Substance(acceptable entry conditions) Measurement results Date & Time Comments
Oxygen(19.5-23.5%)
Flammable Gases (Lessthan10%LFL)
Hydrogen Sulfide (Lessthan10ppm)
Carbon Monoxide (Lessthan35ppm)
Other Gases
Hazard Identification (Applicant shall ensure below but not limited to)
• Has lock out/tag out been performed on all energy sources? • Are appropriate ladders available to safely enter and exit the
• Have entrance openings been properly guarded? space?
• Is the gas monitor properly calibrated? • Have all entrants and attendants reviewed/completed this
• Is a retrieval system and tripod available? permit?
• Is lighting within the space adequate to enter and exit safely? • Did your survey of the surrounding areas how it to be free of
• Measures to control confined space hazards been implemented. hazards such as drifting vapors from tanks or piping?
• Is the ENTRY SUPERVISOR trained in the use of the gas monitor provided? • Have all pumps and lines that may allow contaminants to flow
• Are full-body harnesses sand fall arrest systems available for all entrants? into the space been isolated?

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