HIGH ELEVATION WORK PERMIT F.

HSE-49/R01
IJIN KERJA KETINGGIAN PERMIT NUMBER:
This permit may be applied maximum 1 day work with revalidated 12 hourly (Shift Changed)
Surat Ijin Kerja ini dapat digunakan maksimal 1 hari kerja dengan revalidasi setiap 12 jam (pergantian shift)

Date & Time : Standby/Rescue Personnel

Rig & Location :
Tgl & Waktu
Issued To (Dikeluarkan ke) Specific Work Location (Spesifik Lokasi Kerja) Validation Period 1 Validation Period 2

Department : Validation Period : Time & Date: ……………………….. to……………………………..

Periode Masa Berlaku Jam Tgl.

Detailed description of work to be

performed:
Penjelasan detail dari pekerjaan yang
akan dilaksanakan
JOB REQUIREMENT (PERSYARATAN PEKERJAAN)
YES N/A CONTROLS COMMENTS CHECK ALL PPE
REQUIRED
Full Body Safety Hardness
Tali keselamatan seluruh badan Safety Helmet
Scaffolding Safety Glasses
Perancah Goggles
Anchored examined Face shield
Angker telah diperiksa Safety shoes
Rope Examined
Rubber boots
Tali telah diperiksa
Work gloves
Underneath area is cleared
Area dibawahnya telah bersihkan Hearing protection
Safety Barries Sign Safety Harness
Rambu Penghalang untuk Keselamatan Work vests
Site Watcher SCBA
Pengawas Pekerjaan Dimaksud
Respirator
Others
Lain-lain Others..................

DANGER NOTICES AND ADDITIONAL

SAFETY EQUIPMENT REQUIRED :
Tanda-tanda bahaya dan tambahan
peralatan safety yang diperlukan

AUTHORISATION FOR WORK TO BEGIN / Yang berwenang untuk dimulainya pekerjaan

I hereby certify that it is safe to work on the following equipment.
Dengan ini saya menyatakan pekerjaan aman untuk dikerjakan sesuai dengan pelengkapannya
Permit Applicant Work Permit Authority Client Representative Controlling/Monitoring
Yang Memohon Yang Memberi Ijin Perwakilan Klien

………………………………….. …………………………………. …………………………………. ………………………………….

Name & Position Name & Position Name & Position Name & Position
REVALIDATION PERMIT
Pengesahan ulang Ijin Kerja

Permit Applicant Work Permit Authority Client Representative Controlling/Monitoring

Revalidation Period
Shift Signature, Name & Signature, Name & Signature, Name & Signature, Name &
Time & Date: From …..to………..
Position Position Position Position

AUTHORISATION FOR PERMIT CLEARANCE / Yang berwenang untuk pemeriksaan ijin kerja
I hereby declare that the work for which this Permit was issued is now:
Dengan ini saya menyatakan pekerjaan yang tertera di ijin kerja ini, saat ini dalam status:

Permit Applicant Controlling/Monitoring

Work Permit Authority Client Representative COMPLETED/Telah selesai;
Signature, Name & Signature, Name &
Signature, Name & Position Signature, Name & Position Time & Date:…………………….
Position Position

SUSPENDED/Ditunda ;
Time & Date:……………………..

CANCELLED/Dibatalkan;
Time & Date:………………………
…………………………. …………………………. …………………………. ………………………….

Copy: 1. White - Applicant 2.Pink - Permit Board Worksite 3. Blue - Area Authority 4. Yellow - File