Form :

IZIN KERJA Revisi : Tanggal : / / 20

PEKERJAAN P WATERPROOFING SIKA 107 PADA AREA : Proyek :

A.
Diminta Oleh : I Ketut SuparthaJumlah Tenaga :Orang
1 ..................................................................................... 5 ..................................................................................... 9 .....................................................................................
2 ..................................................................................... 6 ..................................................................................... 10 ...................................................................................

3 ..................................................................................... 7 ..................................................................................... 11 ...................................................................................

4 ..................................................................................... 8 ..................................................................................... 13 ...................................................................................
B.Checklist Hasil Pekerjaan (Diisi oleh Pengawas Pekerjaan)
YATIDAKYATIDAK
Apakah area hasil bobokan sudah siap di waterproofing ?
Apakah area hasil pembersihan sudah siap di waterproofing ?

APD yang wajib dipakai

PELAKSANA KERJA PENGAWAS KERJA PELANGGAN/.....................

Tanggal:
Tanggal : Tanggal :

Nama
Nama : ..
: ............................................................ .......................................................... Nama : ............................................................

Tanda
Tanda Ta ngan
Tangan: ................................................ : ................................................ Tanda Ta ngan : ................................................