LIFTING OPERATION PERMIT

PTW Ref .No: Contractor Name:

Project Name: No. of Employees involved
Starting From Date Time Expected Completion Date Time
Overhead
Lifting Equipment Truck Mounted Crawler Crane Tower Crane
Crane
Details of Load Weight (approx.) Dimension (max) Quantity
Rigger Level Less than 10 ton (Rigger level3) More than 10 to 40 ton (Rigger level 2) More than 40 (rigger level1)
Details of Equip. Serial No Valid Inspection Date Capacity (SWL)
Work Description:

Location of job to be performed:

Tools/Equipment to be used:
Identify risk associated with Lifting work
Toppling/Tip Over/Turn Over Suspended Load High Wind Moving Vehicle/ Equipment
Falling Objects Over Load Tripping / Slipping Noise
Crushing Collapse Near Overhead lines Traffic
Adverse Weather Other(Specify):
The following document must be attached with this permit
Method Statement Risk Assessment Lifting Plan Job Safety Procedure Other (specify):
Precaution require to complete the work safely Yes No N/A
Is the lifting equipment certified by accredited center and complied with SEC list?
Is the operator certified and hold valid license (KSA) to carry out this activity?
Certified: Expiry Date : License: Expiry Date:
Are all accessories inspected (rigging arrangements)? if yes state below
Wire Rope Sling Web Sling Chain Sling Shackles Eye Bolt Other:
Is Load Charts Checked? Is the Load within Crane capability at the given radius of operation?
Is the rigger certified to carry out this activity as per the load limit?
Name of Rigger: Rigger Level: Validity: Expiry Date:
Is wind speed acceptable to proceed the activity? (stop if any dusty wind or more than 32km/h)
Emergency Rescue team and equipment (tower erection) in place?
The following areas / items have been inspected by issuer and receiver
Ground condition Danger/Warning Sign Signal man Safety Barriers
Tag line Rigger Outrigger (extended) Lighting
Out rigger Pad Spreader Beam Man/Material Basket (Certified)
PPE Required for the activity
Helmet Safety Shoes Mechanical Gloves Ear Plugs/muff
Safety goggles Reflective Vest Dust Mask Safety clothes
Other (Specify):
Issue and acceptance before work
Acceptance of Work Permission by the person in-charge (Receiver)
I certify that, I have read and verified this work permit and checklist. I am aware of the risks that can be exposed to. I commit that I will be in line
with all safety rules mentioned in work permit checklist and will not deflect any of them.
Permit Receiver Name: Signature/Date:
Authority to proceed by authorized person (Issuer)
I reviewed the work permission checklist and checked the working conditions. I have reviewed the all aspects of the task/activity and am satisfied
with the arrangements as detailed in the “risk assessment” have been put in place and certify that the activity detailed above is authorized to
proceed
Permit Issuer Name: Signature/Date:
Acknowledge by Contractor's Safety Engineer/Officer
I have reviewed the work permit, and verified entire checklist corresponding to workplace. All the necessary control measures has been taken
according to risk assessment and additional precautions are implemented.
Name : Signature/Date:
Clearance and cancellation after work or Suspension of permit
Clearance. (Site Manager)
All men, materials, tools equipment, housekeeping etc. under my charge have been withdrawn. The permitted work is complete / not complete.
Name: Signature/Date:
Suspension
This permit is suspended, I have notified the Authorized person specified that the work is not complete the area / equipment is not safe to use.
Name: Signature/Date:
 LIFTING OPERATION PERMIT

List of additional precaution measures required (SEC Consultant/ Contractor's Safety Engineer/ Officer)

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Permit Re-Validation

Sl. Receiver Contractor's

Date Time Issuer Signature Remarks
No Signature Safety Signature

This permit is valid for 7 days from the date of issue.