1.

INFORMATION
WORK AT HEIGHT PERMIT 2.RESPONSIBLE PERSON CONTACT NUMBER
HTG RESPONSIBLE ENGINEER NAME AND MOB. NUMBER:
COMPANY（Sub-Contractor) NAME :
PERMIT NUMBER
LOCATION:

DESCRIPTION OF WORK:
Sub-contractor RESPONSIBLE SITE In-Charge & SAFETY OFFICER NAME AND PHONE From Date Time Till Date Time
EQUIPMENT TO USE : NUMBER:
Working Hour:
Daily toolbox talk & JSA shall be attached to the permit
4.HAZARD IDENTIFICATION 5.SAFETY PRECAUTIONS
FILL THE EMPTY BOXES FOR YES "Y" FOR NO "N" NOT APPLICABLE "NA" FILL THE EMPTY BOXES FOR YES "Y" FOR NO "N" NOT APPLICABLE "NA"
Unsafe access
Unguarded openings Toolbox talk is done. Secure Loose Objects

Adverse weather condition Improper scaffold Suitable access and egress is provided Scaffold in place and inspected

Fragile roof Inadequate lighting Barriers and signs are in place Good housekeeping is maintain

Slip & Trip Collapse of structure Fall arrest system Is the weather in good condition

Simultaneous opening Manual handling Is the life line inspected and used. Are the overlap work in safe process.

Falling objects Lack of communication Fixed platform to be provided with guard or handrails Additional Lighting Provided

Unsafe working platform Equipment not maintained Equipment is checked and in good condition. Workers to be aware of emergency procedure

Fall from height Lone working

6.PPE
Safety googles Respiratory protection Dust mask
Electrical hazards Others
Face Shield Hearing protection Positive pressure BA set
Gloves Full Body Harness Others
7.ACCEPTANCE 8.CLOSURE / CANCELLATION
Performing Authority （Sub-Contractor Site In-Charge) Performing Authority（Sub-Contractor Site In-Charge）
The work is finalized
I CONFIRMS THAT EACH OF THE İDENTİFİED CONTROL MEASURES ARE SUİTABLE AND SUFFİCİENT İN THİS PLACE.WORK MAY PROCEED.
Name Signature Date
Name Signature Date JOB COMPLETE

Issuing Authority（HTG Site In-Charge；Construction Dept. etc. If Related） Issued Authority （HTG Site In-Charge；Construction Dept. etc. If Related）
PERMISSION IS GIVEN FOR THE WORK TO PROCEED SUBJECT TO THE CONDITIONS SPECIFIED ABOVE. The work is finalized, work area is clean & secure. All personnel left the area

Name Signature Date

Name Signature Date
JOB COMPLETE

SUB- CONTRACTOR HSE DEPARTMENT HTG HSE DEPARTMENT The work is finalized and this permit is no longer valid.
SUB- CONTRACTOR HSE DEPARTMENT HTG HSE DEPARTMENT
Name Name
Name Name
Signature
Signature Date Signature Date Signature

9 Type the working days in a week

Date

Sub contractor Eng

Sub contractor HSE

HTG Eng

HTG HSE

First copy shall be given to HTG HSE Departmant, second copy shall be kept at the site ready to be shown when requested, third copy shall be given to In-Charge Dept.