JABAL OMAR DEVELOPMENT

PROJECT-MAKKAH
ELEVATED WORK PERMIT
PERMIT NO.

COMPANY:

START DATE:

TIME:

MANPOWER:
DATE EXPIRES:

LOCATION:

TIME EXPIRES:

AREA:

Section A: SAFE WORK PLAN

PROJECT ENGINEER:
Description of the work:

S/N

RESPONSIBLE SUPERVISION (Please Print Name)

SUPERVISOR:
FOREMAN:

HAZARDS

PRECAUTIONS

Section B: PRIOR TO START OF ELEVATED WORK

ENSURE THAT THE FOLLOWING CRITERIA ARE MET
Y

N/A

100% Fall Protection complied.

N/A

N/A

Scaffolds are complete and tagged safe for use.

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Access is clear and free of obstruction. Access

ladder is secured and free of defects.
Full body harness with 2 lanyards and shock
absorber worn where required. 100% PPE
compliance.
Hot Work/Cold Work permit completed where
required.
Safety Officer designated to the area.
Safe Work Plan submitted alongside with
elevated work permit.
Proper
and
adequate
housekeeping
is
maintained.

Cables/cords are raised 6ft. above surface and

safety flags are provided.
Walkway is clear of scattered debris, tools and
materials.
Gas cylinders secured or mounted on a trolley
or rack.
Open areas are adequately covered and
protected. Warning signs are conspicuously
posted
Vertical ladder is not allowed. For elevation
higher than 12ft. side step scaffold is required.
Fire blanket/welding screen for welding,
cutting/grinding works provided.
Elevated work will not be performed above fuel
driven equipment.
Elevation Work has safe access and egress and
secures anchor points.

Section C: AUTHORIZATION TO PROCEED WITH ELEVATED WORK

This is to certify that the above criteria are satisfactorily met and related work permits and safe work
plans are completed.
SITE ENGINEER
NAME (Please Print):

TASK SUPERVISOR/G.FOREMAN/FOREMAN
NAME (Please Print):
SIGNATURE:

DATE:

SIGNATURE:
DATE:

APPROVED BY:
AREA SAFETY SUPERVISOR/SITE SAFETY SUPERVISOR
ZONE MANAGER/PROJECT ENGINEER/LEAD ENGINEER
NAME (Please Print):
NAME (Please Print):

SIGNATURE:
DATE:

SIGNATURE:
DATE:

Section D: EXTENSION OF WORK PERMIT

REQUEST
BY:
APPROVE
D BY:

TASK SUPERVISOR
NAME:

SITE ENGINEER
NAME:

SIGNATURE:
AREA SAFETY SUPERVISOR:
NAME:

SIGNATURE:
SAFETY SUPERVISOR:
NAME:

SIGNATURE:

SIGNATURE:

DATE/TIME EXPIRES:

MANPOWER

ZONE MANAGER/PROJECT ENGG/LEAD

ENGG
NAME:

SIGNATURE: