ELECTRICAL WORK PERMIT FORM

NEW / BARU Permit Number / ®

EXTENTION/PERPANJANGAN Nomor Izin :
PT. P&G OPERATIONS PT. FLUOR DANIEL
INDONESIA INDONESIA

Area : Dept : Validity / Masa berlaku

Published Date / Tanggal dikeluarkan : From / Dari Date/ Tgl : To
Location of Work / Lokasi : Time / Jam : To
Work Executor / Pelaksana Pekerjaan :

Detail of Job / Uraian Pekerjaan :

A. THESE ITEMS BELOW MUST BE CHECKED BY SUPERVISOR / KOLOM KESELAMATAN DI BAWAH INI HARUS DIISI OLEH
SUPERVISOR
√)
(√
NO URAIAN YES / NO / REMARKS / KETERANGAN
YA TIDAK
1 Have employees already understood the detail of job ?
2 Have the employees already understood and been aware of the
hazard of the job & relevant JSA?
3 Has any injury precaution been prepared to ensure that there is no
other job, which can create dangerous situation when this job is to be
executed?
4 Has field operator been contacted ?
5 Has electrical supervisor checked the area and equipment and
ensure that they are in safe condition?
6 Have the main electrical power supplies been disconnected?
7 Have the lock out & tag out system been done on the equipment
8 Are there any other permits needed
9 Advice / Lain-Lain (Saran Tambahan)
10 Special safety instruction from engineer or supervisor (electrical and
instrument)

B. GAS TEST / PEMERIKSAAN GAS DILAKUKAN

STEP / TAHAP TIME / JAM COMBUSTIBLE GAS (%) OXYGEN GAS (%) PETUGAS SAFETY

√)
C. PERSONAL PROTECTIVE EQUIPMENT SHALL BE WORN / ALAT PELINDUNG DIRI YANG HARUS DIPAKAI (√

Safety Helmet / Helm Safety Eye Protection / Pelindung Mata Goggles

Safety Shoes / Sepatu Safety Long sleeve / Baju Lengan Panjang
Ear Plug / Muff / Pelindung telinga Fall Protection / Pelindung Jatuh (Full Body Harness)
Dust Mask / Masker Debu Face Protection / Pelindung Muka
Safety Glass / Kacamata Safety Hand Protection / Pelindung Tangan
Rubber Boot / Sepatu Bot karet Safety Vest / Rompi
Respirator Protection /Pelindung Pernafasan Others / Lain-lain _______________ _____________
SPECIAL INSTRUCTION / INSTRUKSI KHUSUS :

I HAVE READ, UNDERSTOOD AND CHECKED CONDITIONS WHERE THE JOB CAN BE DONE
SAFELY AND AGREE TO OBEY ALL PRECAUTIONS STATED IN THE PERMIT

Name : Name : Name : Name :

Contractor Representative Contractor HSE FLUOR HSE P&G HSE

---------------------------------JOB FINISH OR EXTEND / PEKERJAAN SELESAI ATAU DITUNDA--------------------------------

Job / Pekerjaan Date/ Tanggal Time / Jam I Accept the work (Completed / Extended)*, Work Place Has been cleaned and safe
Finish / Selesai
Extend / Ditunda

Original : Display in Work Area

Copy 1 : P&G Name : Name : Name : Name :
Copy 2 : Originator Contractor
Contractor HSE FLUOR HSE P&G HSE
Representative