Step 4 PTW Coordinator

Permit No:
Working At Heights Date:

Signature:

Step 1 By Permit Holder Diisi oleh permit holder Site Description/ Deskripsi

M/S No. CONTRACTOR NAME:

TYPE OF WORK: Jenis Pekerjaan WORK LOCATION: : Lokasi Kerja:

Scaffolding Roof Work Steel Structure Erecting Tower Climbing

Crane Man-basket Pipe Work Ladders (>3meter) Other :
DESCRIPTION OF THE WORK TO BE PERFORMED: Jelaskan Pekerjaan Yang Dilakukan:

TYPE OF EQUIPMENT TO BE USED (attach if necessary) : Peralatan Yang Digunakan (lampirkan jika dibutuhkan):

PLANNED STARTING DATE : Rencana Tanggal Mulai PLANNED COMPLETION DATE : Rencana Tanggal Selesai

OTHER RELATED PERMIT NO: Terkait Dengan Permit lainnya

SUPERVISOR IN-CHARGE: DATE:

CONTACT NUMBER: SIGNATURE:

Proper fall protection or covering or hard barricade of opening is must prepared to carry out working at height activities. Gunakan pelindung jatuh
yang tepat atau perangakat keras yang terbuka harus dipersiapkan untuk menjaga aktifitas pada ketinggian
The permit (with Method Statement and Risk Assessment) is must be posted at the work site at all times.
Izin Kerja ( dengan metoda kerja dan penilaian resiko harus berada ditempat kerja
This permit is not valid unless all appropriate fields are completed

FORECASTED SPECIAL HAZARD No special hazard

Slip/trip/fall hazard Heat/Cold stress Over Head Activates

Uneven Working Surface Poor Visibility Ergonomics (work position, manual lifting, lighting)

Fall from height Limited Work Area Electrical Lines

Low oxygen concentration Other :

REQUIRED PERSONAL PROTECTIVE EQUIPMENT (PPE) No additional PPE

Safety glasses, hardhat, safety boots, gloves, traffic vest and long sleeves always required.

Face shield Harness & Lanyard Particulate respirators

Hearing protection Fall protection (life line, safety harness) Gas/Vapor respirators

Arc flashes protective equipment Additional clothing Welding air purifying respirators

Special gloves (welding, heat or chemicals or cut resistant, etc.) Powered air-purifying respirators (PAPR)

Other : Self-contained breathing apparatus (SCBA)

OTHER SAFETY REQUIREMENT No additional item required

Handrail in place and secure Fire extinguisher Gas detector Non-sparking tools

Warning signs in place Scaffold Inspected Opening covered and identified Edge protection

Area barricaded below Housekeeping complete Mechanical ventilation Proper anchor pts identified

Level working surface Cables strung overhead Lifeline Ladder

Rescue Procedures in place Inertia Reel Tools Secure Other:

 Step 4 PTW Coordinator

Permit No:
Working At Heights Date:

Signature:

Step 2 By Contractor Area Supervisor / Engineer & EHS Manager

Approved By Name Signature Date

SCT Area Engineer / Supervisor

SCT EHS Manager (Deputy)

Step 3 Review and Approve / Memeriksa dan menyetujui

Approved By Name Signature Date

SCT Site Manager / Construction
Manager

Step 5 Daily Inspection at Worksite / Inspeksi harian di area kerja

Date Date Date Date Date Date Date

Person In Charge/ Penanggung Jawab
Signature Signature Signature Signature Signature Signature Signature

Sub-con. Site Manager or Delegate

SCT Const. Person in charge at Area

SCT EHS Person in charge at Area

Step 6 Permit Close/ Penutupan Permit

The Permit is to be signed off 30 minutes prior to the end of the shift at the last valid day of this permit and reported to SC&T permit coordinator.
Permit akan ditandatangani 30 menit sebelum berakhirnya shift dan diakhir masa berlaku permit serta laporkan ke Permit Kordinator SC&T.
Job Complete/Pekerjaan selesai Job Incomplete/ Pekerjaan belum selesai
I have checked the workplace and declaring that I withdraw all my workforces from the area and it is safe.
Saya telah memeriksa area kerja dan menyatakan bahwa saya telah menarik semua pekerja saya dari dari lokasi kerja dan aman
Permit holder Name and Signature/ Date/
Pemegang Permit dan tandatangan: Tanggal:

SAFETY FIRST!
PTW form rev#4