App 8:

Doc No: BK/SF/04

Rev. 1
PERMIT TO WORK PROCEDURE Page 1 of 1

GIY PHP VN HNH TH H THNG, THIT B IN Giy php s: ....

Permit No:
PERMIT TO WORK FOR ELECTRICAL ENERGIZATION
V tr thi cng/Concerned area: ...................................................................................................................................................
................................................................................................................................................................................................................
Ngy&Gi bt u: .................................................................................. Ngy&Gi kt thc: .................................................
Date & Time Commencement Date & Time Completion:

Ngy v gi xin giy php/Date & Time Of Application: .............................................................................................................

Ngi xin giy php.....................................................Cng ty/ Phng ban: ..................................K tn..................................
Applicants name Company/Dept Signature of applicant
Loi hnh cng vic v mi nguy him/Type of electrical energization work permit to be performed and
hazards: ..........................................................................................................................................................................................
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
c php lm vic nu c bin php an ton sau y c thc hin/Approved as indicated subject to the following safety
precautionary measures:
Hp nhm trc khi bt u cng vic/Tool box talk Yes No N/A
Ngi cnh gii/Standby man Yes No N/A
Trang b bo v c nhn/PPE Yes No N/A
Bao tay cch in/Insulated gloves Yes No N/A
ng cch in/Insulated boots Yes No N/A
nh km LOTO nu cn/List of LOTO if any Yes No N/A
Phn tch an ton cng vic/Job safety analysis Yes No N/A
Cch ly cc hot ng khc/Isolate other activities Yes No N/A
nh sng/Adequate lighting Yes No N/A
S dng b m/Walkie talkies Yes No N/A
C lp ngun in nu c/Electric isolation if any Yes No N/A
Bin bo, hng ro an ton/Notice boards, barrier tapes Yes No N/A
Tip t cho thit b/Connect to earth Yes No N/A
Bnh cha chy/Fire extinguishers Yes No N/A
Cc thit b th phi c kim tra trc khi s dng v trong iu kin tt/
Testing equiments must be checked before operating and in good condition Yes No N/A
[ ] Y/c khc/Others..............................................
.....................................................................................................................................................................................................................................................................

IMPORTANT: Nu mt trong cc bin php trn khng c thc hin th giy php s mt hiu lc
Any changes in the above conditions will immediately invalidate this permit.
Ph duyt / Approved by
Ch nhim Thi cng/ Ngi ph trch Vn hnh v Ch nhim An ton/
Construction Manager S dng thit b in/ HSE Manager
Electrical Energization Leader
Tn/Name
K tn/Signature
Ngy, gi/Date, time

Thng bo hon thnh/ Hu b / Notification of Work Completion/Cancellation

Cng vic hon thnh Cng vic cha hon thnh
Work fully completed Cancellation
Ti xc nhn rng mi trng lm vic ny c dn v sinh L do / Reason
sch v an ton, sn sng tin hnh cng vic li bnh thng / I ...........
aware that the workplace is safe & clear and ready to resume ...............................................................................................
normal operation ...............................................................................................
Tn, chc v / Name, Designation:..................................................................... Ch k / Signature .......................................
Ngy / Date ......................................................................................................... Gi / Time.....................................................
Copy to: All relevant Department, Safety Department, Fabricator