NEOM Operations – Facilities Management

Utility Work Permit

Permit No.: Date Applied: 8/4/2023

DOCUMENTATION REVIEW
Section – I General Information
Permit Category Standard Operational Emergency / Urgent
Work Location Oxagon community SMDB#1 #3
Requester Name Yousef Ahmad SMDB Inside waste management bldg
Minor Work
Contractor Name
Telecom Special Solution Co. Order # (If any)
Work Description SMDB WORKS
From (Date) 8/4/2023 To (Date) 8/18/2023 Total Days 15 Days
Work Permit Coverage
From (Time) 7:00 AM To (Time) 7:00 PM Total time 12 Hours
Associated Permit (If
required)

Section – II Safety Requirement

All requirements mentioned below shall be completed and verified. If “Not”, please “Do Not” proceed.
Yes No N/A Yes No N/A
Does the work require announcement to
1 Back-up plan in place and approved
the community?
9 where shutdown of utility services
Method Statement / Risk Assessment required?
2
provided?
Work area barricaded/ isolated with proper Employees trained & briefed on the Risk
3 10
signage? Assessment and work environment?
Underground service drawing (s)
4 Weather conditions suitable to execute
available?
11 the work?
Service isolated and locked as per LOTO
5 Equipment to be use inspected, tested
procedure? 12
and tagged?
Adequate access provided for pedestrian
13
Underground installations are protected, and utility services vehicles?
6
supported, or removed as required? Road diversion plan approved and in
14
place (if required)?
Hard barriers installed when excavations
Firewatcher trained in extinguish the fire 15
7 are next to roadways?
and initiate the emergency procedure?
Others
Firefighters aware of work and deployed (as
8
required)

Section – III Permit Requester

I have personally inspected to ensure that all requirements & precautionary measures as mentioned above have been fulfilled.

Permit Holder Name Yousef Ahmad Email [email protected]

Signature
Designation Project In Charge Mobile No. 0503323117
Contractor Telecom Special Solution Co.

Contractor Safety Personnel

Name Reneil Ormido Mobile No. 0532165019
Email [email protected] Signature

Section – IV NEOM Proponent / Stakeholder

NEOM Proponent
Name Syed Imran Email [email protected] Mobile No. 0530120720

Designation Public Safety Specialist Signature Remarks

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 NEOM Operations – Facilities Management
Utility Work Permit

Other NEOM Stakeholder/s

Name Fahad Althuwaini Email [email protected] Mobile No. 0530254354
Designation Field Electrical Engineer Signature Remarks
Name Muath Althobaiti Email [email protected] Mobile No. 0565605796
Designation Operation Neom Signature Remarks
Name Elias Deiry Email elias.deiry.com Mobile No. 0567388882
Designation Manager Community Service Signature Remarks
Name Email Mobile No.
Designation Signature Remarks

Section – V NEOM FM H&S Dept.

Remarks:
Name Muhammad Shaukat Email [email protected]

Designation H&S Auditor Mobile No. 0530156300 H&S Auditor

JOINT SITE INSPECTION

Section VI Joint Inspection (Onsite)
Work will only commence after a HSFA site visit ensuring compliance with section II of the PTW and the controls advised within the Risk
Assessment & Method Statement (RAMS)
Remarks:

Permit Requester NEOM Proponent NEOM FM – H&S

Name Name Name

Signature/Date Signature/Date Signature/Date

Section – VII Holding / Stoppage of work

Reason (Holding / Stoppage) Stopped by Time Informed to Restarted time Signature

Section – VIII Extension

The work is not completed, and the renewal of permit requested for additional hours.
Reason for extension
Additional days from From (Date) To (Date) Total Days
Additional hours from From (Time) To (Time) Total time
Requestor
Name Email Mobile No.
Designation Signature Remarks
Approval (NEOM Proponent)
Name Email Mobile No.
Designation Signature Remarks
Approval (FM-H&S)
Name Email Mobile No.
Designation Signature Remarks

Section – IX Permit Closure

Note: I hereby confirm the completion of the work and any alarm, electrical, valves, etc. isolations/ LOTO have been removed. Work area is left
clean, tidy and safe for operational use.
Permit Requester NEOM Proponent NEOM FM – H&S
Name Name Name

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 NEOM Operations – Facilities Management
Utility Work Permit

Signature/Date Signature/Date Signature/Date

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