HOT WORK PERMIT

Day
Permit Registry No.
Night V
TIDAK ADA PEKERJAAN SANGAT MENDESAK YANG MEMBUAT KITA TIDAK DAPAT MELAKUKAN PEKERJAAN DENGAN AMAN
BERHENTI BEKERJA DAN EVAKUASI KETIKA MENDENGAR ALARM DARURAT APAPUN

1. SPESIFIKASI KERJA (by PA)

Lokasi Kerja : WP 7 Jumlah Pekerja : 55
Deskripsi Pekerjaan : WELDING & CUTTING REBAR

CUTTING MACHINE
Equipment & Tools yang digunakan:

Validity: Permit ini berlaku dari TANGGAL 5/9/2023 JAM 18.00 SAMPAI 11/9/2023 JAM 06.00

SUB-Con: PT. HJU Department : CIVIL WORK

Request Oleh : Firman Agus Setiawan Signed : ※ Tugas harus dijelaskan dengan jelas.
2. KEGIATAN BERBAHAYA / BAHAYA DIIDENTIFIKASI (by PA)
Excavation Work Confined Space Lifting operation Live Equipment Radiography
Testing Maintenance Marine Work Diving Work High Voltage
V Low Voltage V Welding sparks Electrical Spark Hot materials Eqpmt causing sparks
Gases/fumes H2S Scaffolding Working at Height V Severe/Adverse Weather
Limited/poor lighting Moving machinery Pintch points Awkward Access/Egress Sharp edges
Manual handling Vibration Electrocution Pressurized Hoses/Lines Unguarded Opening
V Dust/ Powder Hazardous Substances Underground Utility Overhead Power Line Chemical
V Extreme weather Flammable materials Explosives V Noise Vehicle Traffic
Danger of falling Dropped Object V Tripping/Slipping Hazard MAN-BASKET OPERATION Handrail & Grating Removal

Others :
3. SAFETY CHECK (by Performing Authority)
NA * - Not Applicable YES NO NA*
A. Supplementary Requirements B. Site preparations
1 Menyiapkan Risk Assement V
1 Excavation Certificate?
2 Pekerja yang relevan sudah dilatih
2 Confined Space Entry Certificate? - Safety Induction V
- Pelatihan Safety yang Memadai V
3 Lifting Certificate?
3 Apakah semua bahaya diidentifikasi dengan jelas di lokasi? V
4 Radiography Certificate? 4 Semua tindakan pencegahan untuk V
meminimalkan risiko diambil di lokasi? V
5 Electrical Certificate?
5 Hand Tools & Power Tools diperiksa V
6 Electrical Isolation Certificate? 6 Fire Watchman ditunjuk V
7 Peralatan pemadam kebakaran disiapkan V
7 Process Isolation Certificate?

8 Diving Certificate C. Adjacent work site precautions

9 Grating Removal Certificate 1 Apakah pemberitahuan keselamatan tentang
kemungkinan pemblokiran jalan diberikan? V
10 Scaffolding Certificate
2 Apakah arah angin telah dipertimbangkan? V
3 Apakah bahaya dari pekerjaan yang berdekatan
dipertimbangkan? V
4 Apakah ada bahaya radio aktif? V
5 Lock Out & Tag Out V

4. PERHATIAN YANG HARUS DILAKUKAN (by Performing Authority)

V Benar-benar terventilasi Fire hose run out and pressurised V Dilengkapi dengan akses dan jalan keluar yang sesuai

Tes gas dilakukan V Fire resistance blanket/habitat didirikan Area bebas dari bahan yang mudah terbakar
V Maintain radio contact Depressurised Grounding
Water flushed Secure loose objects Drained free of liquids
Distribution - Original(White) : Displayed at Worksite Copy No. 1(Blue) : A
 V Firewatcher present V Containers for welding rods to be provided System Electrically Isolated
V Fire extinguisher N2 Purged / Steam Out System Mechanically Isolated
V Erect signs and barriers V Keep work site free of trip hazards Multi-Lock Isolated
Shoring Slope & Benching V Eye Washer
V Control the working hours Measure the temperature Comply with MSDS
Others : Water station
5. PPE & SAFETY EQUIPMENT REQUIRED (by Performing Authority)
Mandatory Fall Protection Eye & Face & Body Hand Protection Monitoring Equipment Respiratory Protector
V Safety Helmet Full Body Harness V Face Shield Cotton Gloves H2S Badge Half Mask Respirator
V Safety Shoes Fall Arrest Chemical Suit V Leather Gloves Gas Monitor Full Face Respirator

V Safety Glasses Hearing Protection Chemical Boot Lubber Gloves Film Badge/ Dosimeter Dust Mask

V Safety Gloves Ear Plug Rubber Boot Chemical Gloves Survey Meter Breathing Apparatus
Coverall Ear Muff Disposable Suit ETC. Life Jacket/ Vest
V Apron Others :
6. GAS ANALYSIS OR INITIAL GAS TEST( by Authorized Gas Tester)
Not Required Inside Ouside Initial Result Authorized Gas Tester
Oxygen (%) 20.0% ≦O2≦ 20.9% 20.0% ≦O2≦ 20.9% Name
Combustible(%) LEL ≦ 1 % LEL ≦ 10 % Signature
Toxic/H2S H2S ≦ 10 PPM H2S ≦ 10 PPM Date
CO CO ≦ 50 PPM CO ≦ 50 PPM Time
※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. ※ Usable O2 CH4 H2S
※ Comments/Remarks : other sheet CO Other

7. APPROVAL & ISSUE - This permit must be approved when the above precautions are implemented
Step1. Reviewed by (Construction Manager)
Date : 9/4/2023 Time : Name : Hwang Sung Uk Signed :
Step2. Reviewed by (PTW Coordinator)
Date : 9/4/2023 Time : Name : Aldi Irawan Signed :
Step3. Reviewed by (HSE Manager)
Date : 9/4/2023 Time : Name : Kim Hyeong Soo Signed :
Step4. Approved by (Site Manager)
Date : 9/4/2023 Time : Name : Park Kyeong Ho Signed :
Step5. Accepted by (Receiving Authority)
Saya telah membaca dan memahami kondisi dan tindakan pencegahan di atas dan menyatakan bahwa saya menerima tanggung jawab
untuk melaksanakan pekerjaan yang ditentukan dalam Izin ini, bahwa tidak ada upaya yang akan dilakukan oleh saya sendiri atau oleh
orang-orang di bawah kendali saya untuk melakukan pekerjaan lain, dan bahwa saya akan memberi tahu Engineer Kontraktor (HEC)
setelah penyelesaian/penangguhan pekerjaan ini.
Date : 9/4/2023 Time : 11.00 Name : Firman Agus Setiawan Signed :

8. DAILY INSPECTION
Performing Performing
Date Time Authority HSE Area Authority Date Time Authority HSE Area Authority

9/6/2023 11.00 Signature Signature Signature 9/9/2023 11.00 Signature Signature Signature
9/7/2023 11.00 Signature Signature Signature 9/10/2023 11.00 Signature Signature Signature
9/8/2023 11.00 Signature Signature Signature Signature Signature Signature

9. RE-VALIDATION ( Compulsory RE-VALIDATION of the work permit each day - to Continue work )
Performing PTW Performing PTW
Date Time Authority Coordinator Area Authority Date Time Authority Coordinator Area Authority
9/6/2023 13.30 Signature Signature Signature 9/9/2023 13.30 Signature Signature Signature
9/7/2023 13.35 Signature Signature Signature 9/10/2023 13.35 Signature Signature Signature
9/8/2023 13.40 Signature Signature Signature Signature Signature Signature

10. PERMIT CLOSE-OUT ( CLOSURE ) - It must be registered by PTW Coordinator

Requested by(Sub-Contractor) Reviewed by(Construction Manager) Approved by(HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed

Cross-Referenced Documents : YES NO

※ NOTE
Attached File : YES NO
Copy No. 1(Blue) : Area Authority Copy No. 2(Pink) : PTW Coordinator
 COLD WORK PERMIT
Day
Night V Permit Registry No.
TIDAK ADA PEKERJAAN SANGAT MENDESAK YANG MEMBUAT KITA TIDAK DAPAT MELAKUKAN PEKERJAAN DENGAN AMAN
BERHENTI BEKERJA DAN EVAKUASI KETIKA MENDENGAR ALARM DARURAT APAPUN

1. SPESIFIKASI KERJA (by PA)

Lokasi Kerja : WP 7 - JETTY AREA Jumlah Pekerja : 55
FABRICATION & INSTALLATION, REBAR, FORMWORK, POURING CONCRETE
Deskripsi Pekerjaan: & CHIPPING CONCRETE
IN SWI & INTAKE HEAD AREA
GERINDA, CHIPPING MACHINE, TOWER CRANE ETC
Equipment & Tools yang digunakan:

Validity: Permit ini berlaku dari TANGGAL 5/9/2023 JAM 18.00 SAMPAI 11/9/2023 JAM 06.00

SUB-Con: PT. HJU Department : CIVIL WORK

Request Oleh : Firman Agus Setiawan Signed : ※ Tugas harus dijelaskan dengan jelas.
2. HAZARDOUS ACTIVITIES / HAZARDS IDENTIFIED (by Performing Authority)
V Excavation Work Confined Space Lifting operation V Live Equipment Radiography
Testing Maintenance Marine Work Diving Work High Voltage
Low Voltage Welding sparks Electrical Spark Hot materials Eqpmt causing sparks
Gases/fumes H2S Scaffolding Working at Height Severe/Adverse Weather
Limited/poor lighting Moving machinery V Pintch points V Awkward Access/Egress Sharp edges
V Manual handling Vibration Electrocution Pressurized Hoses/Lines Unguarded Opening
V Dust/ Powder Hazardous Substances Underground Utility Overhead Power Line Chemical
V Extreme weather Flammable materials Explosives Noise Vehicle Traffic
V Danger of falling Dropped Object V Tripping/Slipping Hazard MAN-BASKET OPERATION Handrail & Grating Removal

Others :
3. SAFETY CHECK (by Performing Authority)
NA * - Not Applicable YES NO NA*
A. Supplementary Requirements B. Site preparations
1 Menyiapkan Risk Assement V
V 1 Excavation Certificate?
2 Pekerja yang relevan sudah dilatih
2 Confined Space Entry Certificate? - Safety Induction V
- Pelatihan Safety yang Memadai V
3 Lifting Certificate?
3 Apakah semua bahaya diidentifikasi dengan jelas di lokasi? V
4 Radiography Certificate? 4 Semua tindakan pencegahan untuk
meminimalkan risiko diambil di lokasi? V
5 Electrical Certificate?
5 Hand Tools & Power Tools diperiksa V
6 Electrical Isolation Certificate? 6 Heavy Equipment & Machinery are inspected V
7 Process Isolation Certificate? C. Adjacent work site precautions
1 Is notification given to safety about
8 Diving Certificate V
possible road blocks
9 Grating Removal Certificate 2 Has wind direction been considered V
3 Apakah bahaya dari pekerjaan yang berdekatan
10 Scaffolding Certificate
dipertimbangkan? V
4 Apakah ada bahaya radio aktif? V
5 Lock Out & Tag Out V

4. PRECAUTION TO BE TAKEN (by Performing Authority)

V Benar-benar terventilasi Fire hose run out and pressurised V Dilengkapi dengan akses dan jalan keluar yang sesuai
Tes gas dilakukan Fire resistance blanket/habitat erected V Area bebas dari bahan yang mudah terbakar
V Maintain radio contact Depressurised Grounding
Water flushed V Secure loose objects Drained free of liquids
V Firewatcher hadir Wadah untuk batang las harus disediakan Sistem Terisolasi Secara Elektrik

Distribution - Original(White) : Displayed at Worksite Copy No. 1(Blue) : Area A

 V Fire extinguisher N2 Purged / Steam Out System Mechanically Isolated
V Erect signs and barriers V Keep work site free of trip hazards Multi-Lock Isolated
Shoring V Slope & Benching V Eye Washer
V Control the working hours Measure the temperature Comply with MSDS
Others : Water station
5. PPE & SAFETY EQUIPMENT REQUIRED (by Performing Authority)
Mandatory Fall Protection Eye & Face & Body Hand Protection Monitoring Equipment Respiratory Protector

V Safety Helmet V Full Body Harness V Face Shield V Cotton Gloves H2S Badge Half Mask Respirator

V Safety Shoes Fall Arrest Chemical Suit Leather Gloves Gas Monitor Full Face Respirator

V Safety Glasses Hearing Protection Chemical Boot Lubber Gloves Film Badge/ Dosimeter Dust Mask

V Safety Gloves V Ear Plug Rubber Boot Chemical Gloves Survey Meter Breathing Apparatus

Coverall Ear Muff Disposable Suit ETC. Life Jacket/ Vest

Apron Others :
6. GAS ANALYSIS OR INITIAL GAS TEST( by Authorized Gas Tester)
Not Required Inside Ouside Initial Result Authorized Gas Tester
Oxygen (%) 20.0% ≦O2≦ 20.9% 20.0% ≦O2≦ 20.9% Name
Combustible(%) LEL ≦ 1 % LEL ≦ 10 % Signature
Toxic/H2S H2S ≦ 10 PPM H2S ≦ 10 PPM Date
CO CO ≦ 50 PPM CO ≦ 50 PPM Time
※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. ※ Usable O2 CH4 H2S
※ Comments/Remarks : other sheet CO Other

7. APPROVAL & ISSUE - This permit must be approved when the above precautions are implemented
Step1. Reviewed by (Contsruction Manager)
Date : 9/4/2023 Time : 14.00 Name : Hwang Sung Uk Signed :
Step2. Reviewed by (PTW Coordinator)
Date : 9/4/2023 Time : 14.05 Name : Aldi Irawan Signed :
Step3. Reviewed by (HSE Manager)
Date : 9/4/2023 Time : 14.10 Name : Kim Hyeong Soo Signed :
Step4. Approved by (Site Manager)
Date : 9/4/2023 Time : 14.15 Name : Park Kyeong Ho Signed :
Step5. Accepted by (Receiving Authority)
Saya telah membaca dan memahami kondisi dan tindakan pencegahan di atas dan menyatakan bahwa saya menerima tanggung jawab untuk
melaksanakan pekerjaan yang ditentukan dalam Izin ini, bahwa tidak ada upaya yang akan dilakukan oleh saya sendiri atau oleh orang-orang di
bawah kendali saya untuk melakukan pekerjaan lain, dan bahwa saya akan memberi tahu Engineer Kontraktor (HEC) setelah
penyelesaian/penangguhan pekerjaan ini.
Date : 9/4/2023 Time : 11.00 Name : Firman Agus Setiawan Signed :

8. Daily Inspection

Date Validity Time Performing HSE Area Authority Date Validity Time Performing HSE Area Authority
Authority Authority
9/6/2023 11.00 Signature Signature Signature 9/9/2023 11.00 Signature Signature Signature
9/7/2023 11.00 Signature Signature Signature 9/10/2023 11.00 Signature Signature Signature
9/8/2023 11.00 Signature Signature Signature Signature Signature Signature

9. RE-VALIDATION ( Compulsory RE-VALIDATION of the work permit each day - to Continue work )

Date Validity Time Performing PTW Area Authority Date Validity Time Performing PTW Area Authority
Authority Coordinator Authority Coordinator
9/6/2023 13.30 Signature Signature Signature 9/9/2023 13.30 Signature Signature Signature
9/7/2023 13.35 Signature Signature Signature 9/10/2023 13.35 Signature Signature Signature
9/8/2023 13.40 Signature Signature Signature Signature Signature Signature

10. PERMIT CLOSE-OUT ( CLOSURE ) - It must be registered by PTW Coordinator

Requested by(Sub-Contractor) Reviewed by(Constructor Manager) Approved by(HSE Manager)

Date Time Date Time Date Time
Signed Signed Signed

Cross-Referenced Documents : YES NO

※ NOTE
Attached File : YES NO
Copy No. 1(Blue) : Area Authority Copy No. 2(Pink) : PTW Coordinator
 HOT WORK PERMIT
Day V Permit Registry No.
Night
TIDAK ADA PEKERJAAN SANGAT MENDESAK YANG MEMBUAT KITA TIDAK DAPAT MELAKUKAN PEKERJAAN DENGAN AMAN
BERHENTI BEKERJA DAN EVAKUASI KETIKA MENDENGAR ALARM DARURAT APAPUN

1. SPESIFIKASI KERJA (by PA)

Lokasi Kerja : WP 7 Jumlah Pekerja : 91
Deskripsi Pekerjaan : WELDING & CUTTING REBAR

WELDING & CUTTING MACHINE

Equipment & Tools yang digunakan:

Validity: Permit ini berlaku dari TANGGAL 5/9/2023 JAM 7.00 SAMPAI 11/9/2023 JAM 17.00

SUB-Con: PT. HJU Department : CIVIL WORK

Request Oleh : Firman Agus Setiawan Signed : ※ Tugas harus dijelaskan dengan jelas.
2. KEGIATAN BERBAHAYA / BAHAYA DIIDENTIFIKASI (by PA)
Excavation Work Confined Space Lifting operation Live Equipment Radiography
Testing Maintenance Marine Work Diving Work High Voltage
V Low Voltage V Welding sparks V Electrical Spark Hot materials Eqpmt causing sparks
Gases/fumes H2S Scaffolding Working at Height V Severe/Adverse Weather
Limited/poor lighting Moving machinery V Pintch points V Awkward Access/Egress Sharp edges
Manual handling Vibration Electrocution Pressurized Hoses/Lines Unguarded Opening
V Dust/ Powder Hazardous Substances Underground Utility Overhead Power Line Chemical
V Extreme weather Flammable materials Explosives V Noise Vehicle Traffic
Danger of falling Dropped Object V Tripping/Slipping Hazard MAN-BASKET OPERATION Handrail & Grating Removal

Others :
3. SAFETY CHECK (by Performing Authority)
NA * - Not Applicable YES NO NA*
A. Supplementary Requirements B. Site preparations
1 Menyiapkan Risk Assement V
1 Excavation Certificate?
2 Pekerja yang relevan sudah dilatih
2 Confined Space Entry Certificate? - Safety Induction V
- Pelatihan Safety yang Memadai V
3 Lifting Certificate?
3 Apakah semua bahaya diidentifikasi dengan jelas di lokasi? V
4 Radiography Certificate? 4 Semua tindakan pencegahan untuk V
meminimalkan risiko diambil di lokasi? V
5 Electrical Certificate?
5 Hand Tools & Power Tools diperiksa V
6 Electrical Isolation Certificate? 6 Fire Watchman ditunjuk V
7 Peralatan pemadam kebakaran disiapkan V
7 Process Isolation Certificate?

8 Diving Certificate C. Adjacent work site precautions

9 Grating Removal Certificate 1 Apakah pemberitahuan keselamatan tentang
kemungkinan pemblokiran jalan diberikan? V
10 Scaffolding Certificate
2 Apakah arah angin telah dipertimbangkan? V
3 Apakah bahaya dari pekerjaan yang berdekatan
dipertimbangkan? V
4 Apakah ada bahaya radio aktif? V
5 Lock Out & Tag Out V

4. PERHATIAN YANG HARUS DILAKUKAN (by Performing Authority)

V Benar-benar terventilasi Fire hose run out and pressurised V Dilengkapi dengan akses dan jalan keluar yang sesuai

Tes gas dilakukan V Fire resistance blanket/habitat didirikan Area bebas dari bahan yang mudah terbakar
V Maintain radio contact Depressurised Grounding
Water flushed Secure loose objects Drained free of liquids
Distribution - Original(White) : Displayed at Worksite Copy No. 1(Blue) : A
 V Firewatcher present V Containers for welding rods to be provided System Electrically Isolated
V Fire extinguisher N2 Purged / Steam Out System Mechanically Isolated
Erect signs and barriers V Keep work site free of trip hazards Multi-Lock Isolated
Shoring Slope & Benching V Eye Washer
V Control the working hours Measure the temperature V Comply with MSDS
Others : Water station
5. PPE & SAFETY EQUIPMENT REQUIRED (by Performing Authority)
Mandatory Fall Protection Eye & Face & Body Hand Protection Monitoring Equipment Respiratory Protector
V Safety Helmet V Full Body Harness V Face Shield V Cotton Gloves H2S Badge Half Mask Respirator
V Safety Shoes Fall Arrest Chemical Suit V Leather Gloves Gas Monitor Full Face Respirator

V Safety Glasses Hearing Protection Chemical Boot Lubber Gloves Film Badge/ Dosimeter Dust Mask

V Safety Gloves V Ear Plug Rubber Boot Chemical Gloves Survey Meter Breathing Apparatus
Coverall Ear Muff Disposable Suit ETC. Life Jacket/ Vest
V Apron Others :
6. GAS ANALYSIS OR INITIAL GAS TEST( by Authorized Gas Tester)
Not Required Inside Ouside Initial Result Authorized Gas Tester
Oxygen (%) 20.0% ≦O2≦ 20.9% 20.0% ≦O2≦ 20.9% Name
Combustible(%) LEL ≦ 1 % LEL ≦ 10 % Signature
Toxic/H2S H2S ≦ 10 PPM H2S ≦ 10 PPM Date
CO CO ≦ 50 PPM CO ≦ 50 PPM Time
※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. ※ Usable O2 CH4 H2S
※ Comments/Remarks : other sheet CO Other

7. APPROVAL & ISSUE - This permit must be approved when the above precautions are implemented
Step1. Reviewed by (Construction Manager)
Date : 9/4/2023 Time : Name : Hwang Sung Uk Signed :
Step2. Reviewed by (PTW Coordinator)
Date : 9/4/2023 Time : Name : Aldi Irawan Signed :
Step3. Reviewed by (HSE Manager)
Date : 9/4/2023 Time : Name : Kim Hyeong Soo Signed :
Step4. Approved by (Site Manager)
Date : 9/4/2023 Time : Name : Park Kyeong Ho Signed :
Step5. Accepted by (Receiving Authority)
Saya telah membaca dan memahami kondisi dan tindakan pencegahan di atas dan menyatakan bahwa saya menerima tanggung jawab
untuk melaksanakan pekerjaan yang ditentukan dalam Izin ini, bahwa tidak ada upaya yang akan dilakukan oleh saya sendiri atau oleh
orang-orang di bawah kendali saya untuk melakukan pekerjaan lain, dan bahwa saya akan memberi tahu Engineer Kontraktor (HEC)
setelah penyelesaian/penangguhan pekerjaan ini.
Date : 9/4/2023 Time : 11.00 Name : Firman Agus Setiawan Signed :

8. DAILY INSPECTION
Performing Performing
Date Time Authority HSE Area Authority Date Time Authority HSE Area Authority

9/6/2023 11.00 Signature Signature Signature 9/9/2023 11.00 Signature Signature Signature
9/7/2023 11.00 Signature Signature Signature 9/10/2023 11.00 Signature Signature Signature
9/8/2023 11.00 Signature Signature Signature Signature Signature Signature

9. RE-VALIDATION ( Compulsory RE-VALIDATION of the work permit each day - to Continue work )
Performing PTW Performing PTW
Date Time Authority Coordinator Area Authority Date Time Authority Coordinator Area Authority
9/6/2023 13.30 Signature Signature Signature 9/9/2023 13.30 Signature Signature Signature
9/7/2023 13.35 Signature Signature Signature 9/10/2023 13.35 Signature Signature Signature
9/8/2023 13.40 Signature Signature Signature Signature Signature Signature

10. PERMIT CLOSE-OUT ( CLOSURE ) - It must be registered by PTW Coordinator

Requested by(Sub-Contractor) Reviewed by(Construction Manager) Approved by(HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed

Cross-Referenced Documents : YES NO

※ NOTE
Attached File : YES NO
Copy No. 1(Blue) : Area Authority Copy No. 2(Pink) : PTW Coordinator
 COLD WORK PERMIT
Day V Permit Registry No.
Night
TIDAK ADA PEKERJAAN SANGAT MENDESAK YANG MEMBUAT KITA TIDAK DAPAT MELAKUKAN PEKERJAAN DENGAN AMAN
BERHENTI BEKERJA DAN EVAKUASI KETIKA MENDENGAR ALARM DARURAT APAPUN

1. SPESIFIKASI KERJA (by PA)

Lokasi Kerja : WP 7 - JETTY AREA Jumlah Pekerja : 91
FABRICATION & INSTALLATION, REBAR, FORMWORK, POURING CONCRETE
Deskripsi Pekerjaan: & CHIPPING CONCRETE
IN SWI & INTAKE HEAD AREA
GERINDA, CHIPPING MACHINE, TOWER CRANE ETC
Equipment & Tools yang digunakan:

Validity: Permit ini berlaku dari TANGGAL 5/9/2023 JAM 7.00 SAMPAI 11/9/2023 JAM 17.00

SUB-Con: PT.HJU Department : CIVIL WORK

Request Oleh : Firman Agus Setiawan Signed : ※ Tugas harus dijelaskan dengan jelas.
2. HAZARDOUS ACTIVITIES / HAZARDS IDENTIFIED (by Performing Authority)
V Excavation Work Confined Space Lifting operation V Live Equipment Radiography
Testing Maintenance Marine Work Diving Work High Voltage
Low Voltage Welding sparks Electrical Spark Hot materials Eqpmt causing sparks
Gases/fumes H2S Scaffolding Working at Height Severe/Adverse Weather
Limited/poor lighting Moving machinery V Pintch points V Awkward Access/Egress Sharp edges
V Manual handling Vibration Electrocution Pressurized Hoses/Lines Unguarded Opening
V Dust/ Powder Hazardous Substances Underground Utility Overhead Power Line Chemical
V Extreme weather Flammable materials Explosives Noise Vehicle Traffic
V Danger of falling Dropped Object V Tripping/Slipping Hazard MAN-BASKET OPERATION Handrail & Grating Removal
Others :
3. SAFETY CHECK (by Performing Authority)
NA * - Not Applicable YES NO NA*
A. Supplementary Requirements B. Site preparations
1 Menyiapkan Risk Assement V
V 1 Excavation Certificate?
2 Pekerja yang relevan sudah dilatih
2 Confined Space Entry Certificate? - Safety Induction V
- Pelatihan Safety yang Memadai V
3 Lifting Certificate?
3 Apakah semua bahaya diidentifikasi dengan jelas di lokasi? V
4 Radiography Certificate? 4 Semua tindakan pencegahan untuk
meminimalkan risiko diambil di lokasi? V
5 Electrical Certificate?
5 Hand Tools & Power Tools diperiksa V
6 Electrical Isolation Certificate? 6 Heavy Equipment & Machinery are inspected V
7 Process Isolation Certificate? C. Adjacent work site precautions
1 Is notification given to safety about
8 Diving Certificate V
possible road blocks
9 Grating Removal Certificate 2 Has wind direction been considered V
3 Apakah bahaya dari pekerjaan yang berdekatan
10 Scaffolding Certificate
dipertimbangkan? V
4 Apakah ada bahaya radio aktif? V
5 Lock Out & Tag Out V

4. PRECAUTION TO BE TAKEN (by Performing Authority)

V Benar-benar terventilasi Fire hose run out and pressurised V Dilengkapi dengan akses dan jalan keluar yang sesuai
Tes gas dilakukan Fire resistance blanket/habitat erected Area bebas dari bahan yang mudah terbakar
V Maintain radio contact Depressurised Grounding
Water flushed Secure loose objects Drained free of liquids
V Firewatcher hadir Wadah untuk batang las harus disediakan Sistem Terisolasi Secara Elektrik

Distribution - Original(White) : Displayed at Worksite Copy No. 1(Blue) : Area A

 V Fire extinguisher N2 Purged / Steam Out System Mechanically Isolated
V Erect signs and barriers V Keep work site free of trip hazards Multi-Lock Isolated
Shoring V Slope & Benching V Eye Washer
V Control the working hours Measure the temperature Comply with MSDS
Others : Water station
5. PPE & SAFETY EQUIPMENT REQUIRED (by Performing Authority)
Mandatory Fall Protection Eye & Face & Body Hand Protection Monitoring Equipment Respiratory Protector
V Safety Helmet V Full Body Harness V Face Shield V Cotton Gloves H2S Badge Half Mask Respirator

V Safety Shoes Fall Arrest Chemical Suit Leather Gloves Gas Monitor Full Face Respirator

V Safety Glasses Hearing Protection Chemical Boot Lubber Gloves Film Badge/ Dosimeter Dust Mask

V Safety Gloves V Ear Plug Rubber Boot Chemical Gloves Survey Meter Breathing Apparatus

Coverall Ear Muff Disposable Suit ETC. Life Jacket/ Vest

Apron Others :
6. GAS ANALYSIS OR INITIAL GAS TEST( by Authorized Gas Tester)
Not Required Inside Ouside Initial Result Authorized Gas Tester
Oxygen (%) 20.0% ≦O2≦ 20.9% 20.0% ≦O2≦ 20.9% Name
Combustible(%) LEL ≦ 1 % LEL ≦ 10 % Signature
Toxic/H2S H2S ≦ 10 PPM H2S ≦ 10 PPM Date
CO CO ≦ 50 PPM CO ≦ 50 PPM Time
※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. ※ Usable O2 CH4 H2S
※ Comments/Remarks : other sheet CO Other

7. APPROVAL & ISSUE - This permit must be approved when the above precautions are implemented
Step1. Reviewed by (Contsruction Manager)
Date : 9/4/2023 Time : 14.00 Name : Hwang Sung Uk Signed :
Step2. Reviewed by (PTW Coordinator)
Date : 9/4/2023 Time : 14.05 Name : Aldi Irawan Signed :
Step3. Reviewed by (HSE Manager)
Date : 9/4/2023 Time : 14.10 Name : Kim Hyeong Soo Signed :
Step4. Approved by (Site Manager)
Date : 9/4/2023 Time : 14.15 Name : Park Kyeong Ho Signed :
Step5. Accepted by (Receiving Authority)
Saya telah membaca dan memahami kondisi dan tindakan pencegahan di atas dan menyatakan bahwa saya menerima tanggung jawab untuk
melaksanakan pekerjaan yang ditentukan dalam Izin ini, bahwa tidak ada upaya yang akan dilakukan oleh saya sendiri atau oleh orang-orang
di bawah kendali saya untuk melakukan pekerjaan lain, dan bahwa saya akan memberi tahu Engineer Kontraktor (HEC) setelah
penyelesaian/penangguhan pekerjaan ini.
Date : 9/4/2023 Time : 11.00 Name : Firman Agus Setiawan Signed :

8. Daily Inspection

Date Validity Time Performing HSE Area Authority Date Validity Time Performing HSE Area Authority
Authority Authority
9/6/2023 11.00 Signature Signature Signature 9/9/2023 11.00 Signature Signature Signature
9/7/2023 11.00 Signature Signature Signature 9/10/2023 11.00 Signature Signature Signature
9/8/2023 11.00 Signature Signature Signature Signature Signature Signature

9. RE-VALIDATION ( Compulsory RE-VALIDATION of the work permit each day - to Continue work )

Date Validity Time Performing PTW Area Authority Date Validity Time Performing PTW Area Authority
Authority Coordinator Authority Coordinator
9/6/2023 13.30 Signature Signature Signature 9/9/2023 13.30 Signature Signature Signature
9/7/2023 13.35 Signature Signature Signature 9/10/2023 13.35 Signature Signature Signature
9/8/2023 13.40 Signature Signature Signature Signature Signature Signature

10. PERMIT CLOSE-OUT ( CLOSURE ) - It must be registered by PTW Coordinator

Requested by(Sub-Contractor) Reviewed by(Constructor Manager) Approved by(HSE Manager)

Date Time Date Time Date Time
Signed Signed Signed

Cross-Referenced Documents : YES NO

※ NOTE
Attached File : YES NO
Copy No. 1(Blue) : Area Authority Copy No. 2(Pink) : PTW Coordinator
 EXCAVATION CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ EC Registry No.
Related Hot work Permit No.___________________
1. SPESIFIKASI KERJA (BY PA)
Lokasi Kerja : WP 7 - JETTY AREA jumlah pekerja :
Deskripsi Pekerjaan: Manual V Mechanical
EXCAVATION FOR HELPING DRIVING SHEET PILE

Ukuran penggalian : Panjang - M Luas - M Kedalaman - M

Equipment & Tools yg digunakan: Hand tools V Excavator V Trucks Compressor Vibrator
Elec. tools Bulldozer Others :
Validity: Permit ini berlaku dari TANGGAL: 1/31/2023 JAM 7.00 SAMPAI 2/6/2023 JAM 17.00
SUB-Con: PT. HJU Department : CIVIL
Request Oleh : ARIF Signed : ※ Gambar harus disertakan
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. Rambu dan barikade yang memadai disediakan V
- Tanda-tanda reflektif dan pencahayaan yang cukup selama kerja malam disediakan

B. Gambar untuk fasilitas bawah tanah yang ada telah diperiksa V

C. Area diklasifikasikan dalam ruang terbatas (Jika ya, Harap Keluarkan Sertifikat CS) V
D. Banksman disediakan untuk mengontrol peralatan bergerak yang digunakan untuk V
penggalian.
E. Shoring diperlukan untuk melindungi runtuhnya area penggalian V
F. Benda galian & material ditampung minimal 1 meter dari tepi galian. V
G. Akses jalan cukup dan memastikan permukaan tidak licin V
H. Parit atau galian terbuka ke Jalan umum (Blok jalan diperlukan) V
I. Sistem dewatering diperlukan V
3. VERIFICATION (BY EACH RESPONSIBLE PERSON)
A. INSTRUMENT SECTION B. PIPING SECTION
Any telephone cable present in the area : Yes V No Any Pipeline present in the area : Yes V No
Kedalaman kabel : Mts. Kedalaman Pipa : Mts.

C. ELECTRICAL SECTION
Power cable present in the area : Yes V No Tipe Kabel : HV MV LV NA
Kedalaman kabel : Mts. Others :

※ Comments/Remarks :
4. APPROVAL & ISSUE
Step1. Reviewed by ( Construction Manager )
Date : 1/30/2022 Time : Name : Hwang Sung Uk Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : 1/30/2022 Time : Name : Aldi Irawan Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : 1/30/2022 Time : Name : Kim Hyeong Soo Signed :
Comments :

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 CONFINED SPACE ENTRY CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ CS Registry No.
Related Hot work Permit No._________________
1. SPESIFIKASI KERJA (BY PA)
Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: ENTRY AWAL NORMAL ENTRY

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. Apakah semua koneksi ke ruang terbatas telah diisolasi/dihapus?
Jika ya, sertifikat isolasi dilampirkan pada izin?

B. Apakah pekerja dilatih sesuai prosedur untuk masuk ruang terbatas?

(Silakan periksa bersama apakah alat bantu pernapasan akan digunakan)

C. Apakah ruang terbatas tingkat oksigennya cukup memuaskan?

D. Apakah ada sumber kerja panas & radiasi lain di sekitar?
E. Apakah uji gas untuk gas yang mudah terbakar dan gas beracun telah dilakukan?
F. Apakah ventilasi udara paksa terus menerus telah disediakan dan diuji?
G. Apakah Penerangan, Akses, Jalan Keluar, Rambu Peringatan, dan Barikade Cukup?
H. Apakah Standby Man dengan Access / Egress Sheet (Log) berada di tempatnya?
I. Apakah penerangan yang digunakan adalah jenis tegangan rendah? Apakah ELCB
sudah terpasang?
J. Sudahkah pekerja menjalani tes kebugaran medis untuk ruang terbatas?
__________________________________________________________________________________________________________
K. Rencana Penyelamatan diperlukan? (Jika Ya, rencana harus dilampirkan)
______________________________________________________________________________________________________________________
3. GAS ANALYSIS (BY AUTHORIZED GAS TESTER)

Time Initial
Combustible (%) LEL ≦ 10 %
Toxic/H2S H2S ≦ 10 PPM
Oxygen (%) O2 ≧ 19.5 %
CO (%) CO ≦ 50 PPM
AGT's Signature : (Sign) (Sign) (Sign) (Sign) (Sign) (Sign) (Sign) (Sign) (Sign)

8 hourly 4 hourly 1 hourly Continuous Others

※ To be performed at least every 8hrs
※ Initialled by Authorized Gas Tester as being within acceptable gas test limits.
※ Comments/Remarks :
4. APPROVAL & ISSUE
Step1. Reviewed by ( Construction Manager )
Date : Time : Name : Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : Time : Name : Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : Time : Name : Signed :
Comments :

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 GENERAL LIFTING CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ GLC Registry No.
Related Hot work Permit No._________________
1. SPESIFIKASI KERJA (BY PA)
Lokasi Kerja : WP 7 Jumlah Pekerja :
Deskripsi Pekerjaan: V GENERAL LIFITNG WORK CRITICAL LIFTING WORK (Lifting Plan required)
LIFTING LOADING UNLOADING

Validity: Permit ini berlaku dari TANGGAL: 18/7/2023 JAM 7.00 SAMPAI 24/7/2023 JAM 17.00
SUB-Con: PT. HJU Department : CIVIL WORK
Request Oleh : Choi Hoyeoul Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. Operator crane memegang lisensi yang valid dan kompeten V
B. Rute perjalanan derek ditentukan dan Clear V
C. Area operasi Crane ditentukan dan fondasi dudukan Crane kokoh V
D. Fitur keselamatan, rambu peringatan dan barrier disiapkan & didirikan V
E. Area duduk Crane menjaga jarak aman dari penggalian V
F. Kabel daya overhead sudah ada dan perlu dilindungi V
G. Fasilitas Peralatan yang ada di sekitar dijaga V
H. Crane, Lifting Tools, dll. Disertifikasi, diperiksa dengan Color Code V
I. Signalman / flagman yang kompeten dalam posisi ditunjuk dan diposisikan V
J. Apakah pekerja telah menjalani tes kebugaran medis untuk pekerjaan radiografi? V
__________________________________________________________________________________________________________
K. Bahaya dari pekerjaan yang berdekatan dipertimbangkan V
________________________________________________________________________________________________________________________
3. LIFTING INFORMATION (BY PERFORMING AUTHORITY)
Crane Model/ Manufacture : SYM 5300J Crane Total Capacity : 25 (Ton)
Type of Load : REBAR
Lifting Weight Details Lifting Load Chart Details
Chokers/ Sling /Wire rope 0.00005 Ton Work Radius 12 Meter
Crane Hook / Shackles 0.5 Ton Boom Lenth (Degree) 20.5 Meter
Spreader bar Ton Ton
Total Rigging Weight (A) 0.505 Ton Load Chart Capacity (C) 6.7 Ton
Load Weight to be lifted (B) 4 Ton Crane Safety Factor 67.23880597 %
Total Lifting Weight (A+B) 4.505 Ton (A + B) / (C) x 100 < 85 % PASS □ FAIL □

※ Comments/Remarks :
4. APPROVAL & ISSUE
Step1. Reviewed by ( Construction Manager )
Date : 7/17/2023 Time : Name : Hwang Sung Uk Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : 7/17/2023 Time : Name : Aldi Irawan Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : 7/17/2023 Time : Name : Park Kyeong Ho Signed :
Comments :

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 RADIOGRAPHY CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ RC Registry No.
Related Hot work Permit No._________________
1. SPEFISIKASI (BY PA)
Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: Source Curi NORMAL ENTRY

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. Apakah peringatan yang memadai diberikan kepada orang-orang di area tersebut
sebelum dan selama pekerjaan radiografi?

B. Apakah evakuasi semua personel non-radiografi dari area yang tidak aman telah dilakukan?
C. Apakah fitur keselamatan, rambu peringatan dan penghalang didirikan untuk
mencegah orang masuk ke area yang tidak aman?

D. Apakah pekerja yang diklasifikasikan membawa lencana film / dosimeter / Surveymeter?

E. Apakah tindakan pencegahan yang memadai diambil untuk mencegah pemicu detektor
F. Apakah ventilasi udara paksa terus menerus telah disediakan dan diuji?
G. Izin kerja lainnya di area yang terkena dampak ditarik
H. Supervisor Operasi Radiografi berkualifikasi dan ditunjuk
I. Apakah Pencahayaan disiapkan dan memadai?
J. Apakah pekerja telah menjalani tes kebugaran medis untuk pekerjaan radiografi?
__________________________________________________________________________________________________________
K. Emergency Response Plan terlampir?
______________________________________________________________________________________________________________________
3. RADIATION INFORMATION (BY PERFORMING AUTHORITY)
Radioactive Source : X-Ray ISOTOPE Maximum Activity : KILOVOLT/CURIE

Type of Radiation : X-Ray ALPHA BETA GAMMA

Safe Distance Barrier in Meters : METER

Workers Name Badge No. License No. Workers Name Badge No. License No.

※ Comments/Remarks :
4. APPROVAL & ISSUE
Step1. Reviewed by ( Construction Manager )
Date : Time : Name : Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : Time : Name : Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : Time : Name : Signed :
Comments :

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 DIVING CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ DVC Registry No.
Related Hot work Permit No._________________
1. SPESIFIKASI (BY PA)
Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: AIR SATURATION SCUBA REPLACEMENT SURFACE SWIMMING
(Kedalaman Menyelam Air : Max. M)

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
A. Sudahkah item berikut seperti di bawah ini diperiksa dan beroperasi? Yes No N/A Remark
- General system Safety
- Dive Control
- Ruang Kompresi Permukaan
- Launch and Recovery system/ Wet Bell / Diving Basket
- Lift Support Control
- Compressors, Pumps, Personal Equipment?
- High Pressure Gas Storage
- Diver/ Chamber Gas Reclaim and purification
B. Apakah rencana penyelaman & RA sudah ada dan direview ke semua pihak terkait?
C. Apakah keseluruhan sistem komunikasi berfungsi?
__________________________________________________________________________________________________________
D. Bahaya dari pekerjaan yang berdekatan dipertimbangkan
______________________________________________________________________________________________________________________
E. Apakah kondisi lingkungan diperbolehkan untuk menyelam sebagai regulasi dll
F. Apakah bendera, bentuk, atau sinyal lampu yang ditampilkan benar?
G. Rencana Penyelamatan diperlukan? (Jika Ya, rencana harus dilampirkan)
H. Apakah hal-hal di bawah ini sudah ditangani?
- Pompa air pemadam kebakaran / Caisson terisolasi atau manual
- Larangan mengangkat di atas air (Parameter luar platform)
- Larangan untuk penggangguan Vessel/ Pergerakan
- Larangan kegiatan di atas kapal/di atas perairan

※ Comments/Remarks :

3. APPROVAL & ISSUE

Step1. Reviewed by ( Construction Manager )
Date : Time : Name : Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : Time : Name : Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : Time : Name : Signed :
Comments :

4. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 GRATING REMOVAL CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ GR Registry No.
Related Hot work Permit No._________________
1. SPESIFIKASI (BY PA)
Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: Floor Removal Grating Removal Handrail Removal

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. Rencana plot area yang menunjukkan lokasi yang tepat di mana grating harus
dilepas.

B. Rambu peringatan dan pembatas yang disiapkan sudah tepat dan memadai
C. Pemotongan panas diperlukan untuk memotong grating (Izin kerja panas harus dikeluar
(Jika ya, izin kerja panas harus dikeluarkan)
D. Harness seluruh tubuh disediakan untuk pekerja
E. Area bawah aktivitas removing grating dibarikade & ditandatangani
F. Bahaya dari pekerjaan yang berdekatan dipertimbangkan
G. Perlindungan & pencegahan jatuh untuk pekerja disiapkan dan memadai
H. Tempat kerja cukup terang
I. Grating harus diangkat dan dilepas dengan metode yang tepat
J. Semua area kerja yang membutuhkan Flooring Removal diisolasi oleh barikad
K. Lubang terbuka ditutup dengan bahan penutup atau barikade yang cukup.
※ Comments/Remarks :

3. APPROVAL & ISSUE

Step1. Reviewed by ( Construction Manager )
Date : Time : Name : Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : Time : Name : Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : Time : Name : Signed :
Comments :

4. PEMULIHAN WILAYAH KERJA / PENUTUPAN IZIN SETELAH KERJA SELESAI (BY AREA AUTHORITY)

Yes No N/A Remark

A. Pemulihan Grating, Clip terpasang:
B. Pemulihan Opening Cover
c. Pemulihan Handrail:
Jika "tidak", dalam kondisi berikut::

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 SCAFFOLDING CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ SFC Registry No.
Related Hot work Permit No._________________
1. SPESIFIKASI KERJA (BY PA)
Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: INSTALLATION DISMANTLE MODIFICATION

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. Perlindungan publik yang memadai telah disediakan
B. Pengamanan yang memadai terhadap jaringan listrik telah disediakan
C. Rambu peringatan dan pembatas yang disiapkan sudah tepat dan memadai
D. Pekerja Scaffolding memenuhi syarat dan terlatih dalam prosedur
E. Perlindungan yang memadai untuk benda jatuh telah disiapkan
D. Full Body Harness disediakan untuk pekerja
E. Perlindungan & pencegahan kejatuhan pekerja disiapkan dan memadai
F. Bahaya dari pekerjaan yang berdekatan dipertimbangkan
G. Tempat kerja cukup terang
H. Bahan Scaffolding diperiksa dan diverifikasi sebagai peraturan
I. Kondisi scaffolding ground erecting cukup kuat
J. Area penyimpanan bahan perancah ditentukan dan sesuai
K. Semua bahaya diidentifikasi dan tindakan pencegahan diterapkan
L. Gambar pendirian Scaffolding (Rencana) disetujui dan dilampirkan

※ Comments/Remarks :

4. APPROVAL & ISSUE

Position Name ID No. Certificate No. Remarks
Scaffolding Supervisor
Scaffolding Foreman
Scaffolding Inspector
※ Scaffolding tagging system is mandatory implemented after the completion of the scaffolding inspection

4. APPROVAL & ISSUE

Step1. Reviewed by ( Construction Manager )
Date : Time : Name : Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : Time : Name : Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : Time : Name : Signed :
Comments :

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 ELECTRICAL CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.______________________ ELC Registry No.
Related Hot work Permit No._________________
1. SPESIFIKASI KERJA (BY PA)
Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: WORK ON ENERGIZED AREA ELECTRICAL ISOLATION REQUIRED
- Silakan isi & lampirkan sertifikat isolasi listrik

HIGH VOLTAGE MEDIUM VOLTAGE LOW VOLTAGE ( Tick as Applicable )

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. SAFETY CHECK (BY PERFORMING AUTHORITY)
Yes No N/A Remark
A. APD & peralatan keselamatan disediakan
- Sarung tangan karet isolasi
- Sepatu boots karet isolasi
- Mat karet isolasi
- Alat dan peralatan penyelamatan darurat lainnya

B. Pemberitahuan bahaya & peringatan telah diposting

C. Area kerja dipagari atau diikat dengan tali atau disaring
F. Jarak aman dari Energized Line dijaga
G. Para pekerja memenuhi syarat untuk mengakses dan bekerja di Energized Area
H. Para pekerja dilatih dalam tanggap darurat untuk masalah kelistrikan
I. Perlindungan untuk Kabel listrik diperlukan
J. Grounding sudah cukup
___________________________________________________________________________________________________________
K. Bahaya dari pekerjaan yang berdekatan dipertimbangkan
______________________________________________________________________________________________________________________
4. APPROVAL & ISSUE
Step1. Reviewed by ( Construction Manager )
Date : Time : Name : Signed :
Comments :
Step2. Reviewed by (PTW Coordinator )
Date : Time : Name : Signed :
Comments :
Step3. Approved by ( HSE Manager )
Date : Time : Name : Signed :
Comments :

5. CLOSE-OUT (CLOSURE) - It must be registered by PTW Coordinator

Closed by(Performing Authority) Reviewed by (PTW Coordinator) Accepted by (Area Authority)
Date Time Date Time Date Time
Signed Signed Signed
 ELECTRICAL ISOLATION CERTIFICATE
(SERTIFIKAT INI UNTUK DIGUNAKAN DENGAN IZIN KERJA YANG RELEVAN)
Related Cold work Permit
No.____________________ EIC Registry No.
Related Hot work Permit No.________________

1. SPESIFIKASI (TO BE COMPLETED BY PA)

Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: Isolation De-Isolation

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. ADJACENT WORKGROUPS (TO BE COMPLETED BY PA)
Number Location of work Work Description
Hot work Permit
Sertifikat ini digunakan Cold Work
bersama dengan Izin /
Sertifikat berikut: Entry Certificate
Process Isolation
Other

3. TYPE OF DE/ISOLATION ( TO BE COMPLETED BY ISOLATING AUTHORITY )

HIGH VOLTAGE MEDIUM VOLTAGE LOW VOLTAGE ( Tick as Applicable )

Switch Fuses/Breaker
Tag/Equipment No. Description/Function Removed Remark
OFF ON YES NO

Step1. Confirmed by (Electrical Isolating Authority)

Date : Time : Name : Signed :
Comments :

4. APPROVAL & ISSUE

Step1. Reviewed by (Construction Manager)
Date : Time : Name : Signed :
Comments :
Step2. Approved by (HSE Manager)
Date : Time : Name : Signed :
Comments :

5. IMPLEMENTATION - Pastikan untuk melakukan De/Isolasi sebelum memulai pekerjaan

Implemented by (Sub-Contractor) Checked by (Construction Manager) Confirmed by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed

※ Caution : Additional padlock MUST be provided to Performing Authority if multiple lock is applicable
6. CLOSE OUT (RESTORATION) - Pemeriksaan di tempat kerja harus dilakukan sebelum memasok energi ke area tersebut
Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed
 Signed Signed Signed

Step1. Approved by (Approving Authority)

Date : Time : Name : Signed :
Step2. Implemented by (Electrical Isolating Authority)
Date : Time : Name : Signed :
 PROCESS ISOLATION CERTIFICATE
Related Cold work Permit
No.______________________ PIC Registry No.
Related Hot work Permit No._________________

1. SPESIFIKASI KERJA (TO BE COMPLETED BY PA)

Lokasi Kerja : Jumlah Pekerja :
Deskripsi Pekerjaan: Isolation De-Isolation

Validity: Permit ini berlaku dari TANGGAL: JAM: SAMPAI: JAM:

SUB-Con: Department :
Request Oleh : Signed : ※ Tugas harus dijelaskan dengan jelas.
2. ADJACENT WORKGROUPS (TO BE COMPLETED BY PERFORMING AUTHORITY)
Number Location of work Work Description
Hot work Permit
Sertifikat ini digunakan Cold Work
bersama dengan Izin /
Sertifikat berikut: Entry Certificate
Process Isolation
Other

3. TYPE OF DE/ISOLATION ( TO BE COMPLETED BY ISOLATING AUTHORITY )

High Pressure Water Air Base Oil ( Tick as Applicable )
Low Pressure Oil Gas Chemical

Valve/ Switch Blind/ Spade

Tag/Valve/Switch No. Description/Function Remark
OPEN SHUT YES NO

Step1. Confirmed by (Process Isolating Authority - Process Responsible Person)

Date : Time : Name : Signed :
Comments :

4. APPROVAL & ISSUE

Step1. Reviewed by (Construction Manager)
Date : Time : Name : Signed :
Comments :
Step2. Approved by (HSE Manager)
Date : Time : Name : Signed :
Comments :

5. IMPLEMENTATION - Pelaksanaan Isolasi harus dilakukan sebelum menyetujui PTW

Implemented by (Sub-Contractor) Checked by (Construction Manager) Confirmed by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed

※ Caution : Additional padlock MUST be provided to Performing Authority if multiple lock is required

6. CLOSE OUT (RESTORATION) - Pemeriksaan di tempat kerja harus dilakukan sebelum memasok energi ke area tersebut
Closed by (Sub-Contractor) Reviewed by (PTW Coordinator) Accepted by (HSE Manager)
Date Time Date Time Date Time
Signed Signed Signed

Step1. Approved by (Approving Authority)

Date : Time : Name : Signed :

Step2. Implemented by (Process Isolating Authority)

Date : Time : Name : Signed :
 ELECTRICAL MASTER ISOLATION REGISTER
Date :
ISOLATION METHOD
Isolation Isolation Fuses/ Breaker Isolated By De-Isolated By
S/N Description Switch Lock Out Tag Out
Point Certificate No. Removed
On Off Yes No Yes No Yes No Yes No Name/Date Name/Date
 PROCESS MASTER ISOLATION REGISTER
Date :
ISOLATION METHOD
Isolation Isolation Isolated By De-Isolated By
S/N Description VALVE LOCK OUT TAG OUT BLIND/ SPADE
Point Certificate No.
Open Shut Yes No Yes No Size Status Name/ Date Name/ Date
 PTW (Permit To Work) LOG SHEET
PROJECT NAME :

No. PTW Number Issued Date Expired Date Type of PTW Day/ Night Area Task Description Company Discipline Performing Authority Area Authority Receiving Authority Status Comments