SBC/OSHE/PTW - A000001

PERMIT TO WORK APPLICATION FORM

DOES THE WORK INVOLVES THE USE OF THE FOLLOWING:-

GENERAL ACTIVITIES WORKING AT HEIGHT (2 METERS AND ABOVE)

Risk Level: High Medium Low

MINIMUM REQUIREMENT
ITEM Please tick ()

1. Safety Induction - CIDB/NTMSP(Valid)

2. Risk Assessment (HIRARC)

3. Personal Protective Equipment (PPE)

4. Valid WAH Certification

Section A & B to be fill up by vendor/suppliers/contractor

SECTION A
Company Name : Date :
Person In Charge : IC No :
Address Fax no
: :
Email :

Contact No
:

Purchase Order / Work

Order /Contract No
:

* The contractors assigned must provide ONE supervisor to supervise at sites until the task is completed and compliance to Dept of Occupational Safety
and Health (DOSH) / Occupational Safety and Health Act 1994(OSHA) ,other Local Authority and relevant party requirements.A permit will not be issued until
evidence has been demonstrated that the place of employment will be safe and healthful.The Division reserves the right to revoke or suspend a permit if it
is unable to promptly verify compliance with the terms and conditions of the permit

SECTION B
Particular of work
Type of work : Please Specify : ______________________
Type of activity : Inspection / Maintenance / Installation / Others :________________________________

Location / Site Name :

Description of job :

Start Date / time : End Date / time

:

Details of Staff:-
Name IC No/ Passport No Phone No Designation

DECLARATIONS BY CONTRACTOR TO COMMENCEMENT

I understand and accept all the terms and conditions the work prescribed is to be carried out and safety precautions that are necessary to complete the work safely as outlined in the
appropriate method statement and risk assessments. If conditions are such that the method statement and risk assessments become invalid it is my responsibility to stop work
immediately and notify the person who authorised this permit to work. The disposal of any residues of the hazardous material used will be in accordance with the Environmental
Quality Act. The person who undertake this work also liable to comply to all the Statutory Requirement imposed by the authorities.

Signature, Name of Applicant & Company chop Date & Time :

Contractor
Name

IC No

Designation
 PERMIT TO WORK (cont')
Section C & D to be fill-up by project owner

SECTION C

* In-case of emergency please call

Name :

Contact No : or 999 ( nearest Police Station / Bomba / Hospital )

Start Date : End Date :

Time in : Time Out
:

I hereby certify that to the best of my knowledge all information and assertions made on the Permit Application and/or Activity Notification Form
are true and correct and that I/the applicant have knowledge and will comply with the foregoing

Verified by: Approved by:

Signature Signature
(Designated Person) (Site Access/Owner)
Name : Name :
Date Date

SECTION D
Status of Work Permit

Result: Extension of PTW Incomplete Completed

Extension of Permit To Work

Permit has been extended from (Start Time) : ____________________________ until (End Time) : _____________________________

Comment :

Incomplete Work ( Non Compliance)

Comment :

Completed Work
*Contractors must clear all debris at site after work completed and ensure accordingly disposed.

Comment :

Signed by : Concurred by,

Signature Signature
Contractor ( Supervisor) (Project Owner/Immediate Superior)
Name Name :
Date : Date

Distribution copy : Copy of this form should be kept by Contractor Supervisor for Inspection and supervision at sites.
Copy of closed work permit to be submitted to Project Owner for recording purposes ( 7 years )

Note: Should you require site key, please refer to Site Owner.
STATE BACK COMPANY COMPANY 'S
LOGO
OCCUPATIONAL SAFETY & HEALTH UNIT
CORPORATE HUMAN RESOURCE

TOOLBOX MEETING CHECK LIST

Contractor

Name:

IC No :

Date : Time :

Task :

Before
Yes No Remarks :
1- Fitness
2- Certificate NTMSP/CIDB
3- WAH Certificate competency
4- Permit to Work
5- Guide line and SOPP
6.To complete HIRARC Form
7.Others safety control measures
8. Personal Protective Equipment

During
Yes No Remarks :
1- No Horse Play
2- Observe weather condition
3- Supervisions
4- Buddy System
5- No activities shall be allowed
under the tower during WAH
6. Personal Protective Equipment

After
Yes No Remarks:
1- Site Inspections after work completed
2- 5S Housekeeping

Note:
We declared, understood and agreed to all the terms and conditions the work prescribed is to be
carried out and safety precautions that are necessary to complete the work safely as outlined in
the appropriate method statement and risk assessments. The person who undertake this work also
liable to comply to all the Statutory Requirement imposed by the authorities.

Contractor Supervisor by :
(Name/ I.C / Staff No)
Company Name :
Tel No:
* Copy of Safety Briefing to be kept by Project Owner