You are on page 1of 4

COLD WORK PERMIT

Name of Project : PRIORITY WORKS (STREET LIGHTING, STORM WATER DRAINAGE AND KERBS) SOUTH EAST SEC
Work location :

Pemi

Permit Validation

From

Date:
Time :

Expire

Da
Tim

Description of Work :

Hazard Identied

Special Precautions

Permit is valid only if the conditions existing at the time of issuance continue. It expires upon occurrence(s) gas leak, liqu

Safety Measures

YES

No

N/A

Has the work area been inspected and reasonable precaution taken to ensure that no potential
hazards exist?
Necessary barricades, warning signs in place in the area
Workers been inducted and safety oriented to the job being perform.
TBT held prior to start the work.
Necessary Personal Protective equipments provided to the workers.
Flagmen / banksmen assigned to control the traffic

Permit Rquested by:

I understand and agree that no work is permitted other than that specified on this permit. I have check both permit and the job, and understand
work and precaution to be followed in completing the work
Engineer / Supervisor/

Signature :

Date :

Signature :

Date :

Signature :

Date :

Asphalt foreman

Checked by:
Safety Officer

Issued by:
Project Engineer

PERMIT CLOSE OUT


Close out requested by:
I have closed the work;removed all materials and made the area safe
Engineer/ Supervisor

Signature :

Date :

Signature :

Date :

Close out area checked by:


Safety Officer

Revision 0

AGP/HSE/SF/045

Permit Closed by:


Project Engineer

Revision 0

Signature :

Date :

AGP/HSE/SF/045

AST SECTORS IN KC-ZONE 4/1


Pemit No :
Date :
Time:

s leak, liquid spills

N/A

Remarks

nderstand the nature and extend of the


Time :

Time :

Time :

Time :

Time :

Revision 0

AGP/HSE/SF/045

Time :

Revision 0

AGP/HSE/SF/045