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Permit - Rev 1

The document is a work permit application for a shoe factory project. It provides information on the contractor, supervisor, safety officers, number of workers, job description, required PPE, attached documents, tool conditions, and hazard controls. Signatures are required from managers and supervisors to approve the permit.

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Ridwan Ono
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14 views1 page

Permit - Rev 1

The document is a work permit application for a shoe factory project. It provides information on the contractor, supervisor, safety officers, number of workers, job description, required PPE, attached documents, tool conditions, and hazard controls. Signatures are required from managers and supervisors to approve the permit.

Uploaded by

Ridwan Ono
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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WORK PERMIT

Name Project PCG Central Java Industrial Shoes Factory Date of filing

Contractor Name Date Period S/D

Supervisor Time S/D

SHE Officer Number of workers Workers


Job location
Job Description
No PTW -SH&E/PTW/WP2/ /24

Y N PPE to be used
Approved Method statement attached No MS : Helmet, vest, safety shoes (mandatory)
Approved SWP & JSA attached No JSA : Others:

Update Drawing location attached


All tools and equipment in good condition
Works not creating safety hazard for its surrounding
No pending technical issues related this work
Specific Hazard and control measure :

Noted : High-risk work activities must obtain separate permits,


Please attach the name of the worker

Permit Validation Applicant ISSUER A Knowledge


CREMONA DELTA RADIAN
Contractor Site Manager Contractor SHE Manager PCG-HAI
CSA/MEP SHE

Supervisor in charge* :

SHE supervisor in charge :


by signing this form the Applicant understands and agrees te he is responsible to ensure the work will be conducted in a safe manor and in compliance with the work instruction
file , and the agreed safety standards based on safety procedure. *supervisor shall conduct daily checklist

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