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Work Order No

This document appears to be a work permit issued by CV. Al Hikmah Mandiri for a subcontractor. It contains information such as the work order and permit numbers, location, dates, description of work, required safety equipment, and signatures for approval and closure of the work. The subcontractor must follow all mentioned safety precautions and use the listed personal protective equipment, and electrical or confined space permits may be required depending on the work.

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Syahrial Prasetya
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350 views2 pages

Work Order No

This document appears to be a work permit issued by CV. Al Hikmah Mandiri for a subcontractor. It contains information such as the work order and permit numbers, location, dates, description of work, required safety equipment, and signatures for approval and closure of the work. The subcontractor must follow all mentioned safety precautions and use the listed personal protective equipment, and electrical or confined space permits may be required depending on the work.

Uploaded by

Syahrial Prasetya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CV.

AL HIKMAH MANDIRI

Work Order No.: _________________ Work Permit No.: ____________________________


Location: _________________
WORK PERMIT Issue Date: ____________________________

SUBCONTRACTOR ____________________________________AREA OF W ORK ______________________________________

WORK STARTING DATE _______________ TIME __________ WORK ENDING DATE _____________ TIME ________________

DESCRIPTION OF THE W ORK _______________________________________________________________________________


___________________________________________________________________________________________________________

WORK EQUIPMENT _________________________________________________________________________________________


___________________________________________________________________________________________________________
SUBCONTRACTOR
TO BE FILLED BY

Subcontractor receiving Authority _ _ _ Date Time _ _

Subcontractor performing Authority ______________________________________________ Date ________ Time __________

The above signing person is responsible to ensure the work is performed under all the mentioned and required safety precautions.
Failure on this will be subject to disciplinary actions.

INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X):


□ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves
□ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses
□ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask
□ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness
TO BE FILLED BY CONTRACTOR

□ Dust Mask □ □ □ □ __________

COMMON PROTECTION EQUIPMENT _________________________________________________________________________


__________________________________________________________________________________________________________

OTHER SAFETY MEASURES _________________________________________________________________________


__________________________________________________________________________________________________________

Contractor Issuing Authority ___________________________________________________Date ________ Time _________

Is Electrical PTW required Is Confined Space PTW required In case Electrical or Confined Space PTW is
YES ___ NO ___ YES ___ NO ___ required? YES ___ NO ___
PTW Number PTW Number If yes, attach a Copy.

Site Preparation completed and work can commence. I understand the precaution to be taken as described above.
Contractor Operating Authority Sub-Contractor Operating Authority

The Work is completed and working area cleared The Site has been checked and working Area accepted

_____________________________________ ________________________________________
CLOSURE

Subcontractor performing Authority Contractor Operating Authority


CV. AL HIKMAH MANDIRI

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