EHS-Checklists-And-Forms

Permit No:

Sub Permit No.

Valid for 7 days from the date & time specified. Sketch and checklist to be attached where applicable

Part 1A: Application – to be submitted by 1st Tier Sub-Contractor PM / CM

Work Performed by (Company name & Trade) : MAGICSOFT ASIA SYSTEMS 

Name of PM / CM: Magicsoft .

Contact No: text

Location & description of work Use Appendix-A activity (Attach Layout plan) :Use Appendix-B (Job requires Lock Out Tag Out (LOTO) & add-on job)

Work requires Lock Out Tag Out?: YES

If yes, state number of work processes that requires LOTO: (Please use appendix-B for the task requires LOTO)

To facilitate LOTO do you required to;

If yes, (Please highlight in appendix-A and apply separate sub-permit for WAH and/or confined space entry permit to facilitate LOTO)

1. Work at height (WAH): YES 

2. Enter into confined space: YES

Date & Time of Work:

From: 12/12/2017 15:46

To: 12/12/2017 15:46

No. of Persons : text

Type of Permit-to-work (PTW) / Checklist (select only one unless the work process requires > 1 PTW)

☐ Work at height (>2m)

☐ Excavation work(>1.5 m)

☐ Lifting operation

☐ Hot work

☐ Confined Space Work

☐ Piling work

☐ Tunnelling work

☐ Demolition Work

☐ Works Above Clean Room Ceiling

☐ Floor opening / Raised Floor/ Barricade Removal Checklist

Part 1B: Checking, Evaluation, Assessment & Review of EHS Requirements – By Sub-Contractor EHS Personnel

– I confirm that the work area(s) stated in the appendix is/are safe and environment aspects are eliminated.

– All reasonably practicable measures are taken to safeguard the safety and health of work personnel and preservation of the environment.

EHS Personnel Name & Sign: – –

Date & Time: –

PM/CM Name & Sign: Magicsoft .

Date & Time: 12/12/2017 15:46

Part 2: Final Review and Assessment of EHS Requirements by Safety Assessor (M+W EHS Department)

– I have reviewed the risk assessment and EHS requirements for the intended work(s) and I am satisfied with the control measures

– The work shall be stopped and the permit will be void if there is any change in work conditions

– Additional instructions (if any): 

Name & Sign: – –

Date & Time: –

Part 3: Approval by Authorized Manager (M+W Project Manager / Construction Manager)

– I am satisfied that all reasonably practicable measures are/will be implemented, enforced and the working personnel are informed of the safety hazards and environmental impacts and protection counter measures to be taken.

– Sub-contractors are instructed that any work not stated in the description (Appendix-A and B (for add-on job)) shall not proceed.

– Additional instructions (if any):

Name & Sign: – –

Date & Time: –

Part 3A: Permit Revocation by Authorized Manager (M+W Project Manager / Construction Manager)

This Permit-To-Work is REVOKED and associated activities shall CEASE IMMEDIATELY

– Reason(s): – –

– Revoked by Authorized Manager (Sign, date, time) –

– Acknowledged by PTW applicant (Sign, date, time)

Part 4: Closure of Permit-To-Work by 1st Tier Sub-Contractor PM / CM

I confirmed that the work has completed, the work area has been checked & cleared and no new hazard is introduced.

Sub-con PM / CM: (Name & Sign) – –

Date & Time: –

Verified by M+W System Supervisor / Engineer

(Name & Sign) – –

Date & Time: –

Note: A copy of this approved Parent Work Permit to be displayed in specified location throughout the duration of work. Individual permit shall be displayed at the work location