Permit No.

COMPANY NAME
PROJECT NAME

Demolition Work/ Working at Height(More than 2m) Permit-To-Work

(Delete where not applicable) Permit-To-Work to be displayed at work area

Application : :

a) Location of Work b) Description of Work

c) Date/s of Work d) Time of Work

: From: To:

e) The following safety equipment/special provisions must be provided and maintained throughout the work. Barricades/ Warning Signs Non-sparking Tools Hard Hat Access Ladders Safety Harness with lifeline Dust Masks Marshal/ Stand by man Others (Please Specify)

. .
(Please tick where appropriate) f) Name of Competent Person:

Safety Assessor g) No. of Workers :

Supervisor

h) I wish to carry out the above work, I undertake to comply with the requirement stated above and maintain them throughout the work. I have read and understood the Permit-To-Work and shall comply with General Safety Procedure.

Name

: PTW Applicant

Signature

Date

i)

I certify that the above high-risk construction work can be carried out in the worksite and practicable measures have been taken to ensure the safety and health of the persons. Remarks : Name : Safety Assessor Signature : Date :

j) Permit for above high-risk construction work is hereby approved. Remarks Name : : Project Manager Signature 2 : Date :

Completion of work by PTW applicant The work completed and all persons under my supervision, materials and equipment are withdrawn. The Permit-To-Work is returned to the Project Engineer/Project Manger for cancellation. Name : PTW Applicant

Signature 3

Date

Cancellation of Permit-To-Work

a) I have checked the work area. b) This Permit-To -Work is now cancelled. Name : Project Manager Signature : Date :