JABAL OMAR DEVELOPMENT PROJECT-MAKKAH

ELEVATED WORK PERMIT

PERMIT NO.COMPANY:MANPOWER:

START DATE:TIME:DATE EXPIRES:TIME EXPIRES:

LOCATION:AREA:

Section A: SAFE WORK PLAN

RESPONSIBLE SUPERVISION (Please Print Name)

PROJECT ENGINEER:SUPERVISOR:FOREMAN:

Description of the work:

S/NHAZARDSPRECAUTIONS

Section B: PRIOR TO START OF ELEVATED WORK

ENSURE THAT THE FOLLOWING CRITERIA ARE MET

YNN/A100% Fall Protection complied.YNN/ACables/cords are raised 6ft. above surface and safety flags are provided.

YNN/AScaffolds are complete and tagged safe for use.YNN/AWalkway is clear of scattered debris, tools and materials.

YNN/AAccess is clear and free of obstruction. Access ladder is secured and free of defects.YNN/AGas cylinders secured or mounted on a trolley or rack.

YNN/AFull body harness with 2 lanyards and shock absorber worn where required. 100% PPE compliance.YNN/AOpen areas are adequately covered and protected. Warning signs are conspicuously posted

YNN/AHot Work/Cold Work permit completed where required.YNN/AVertical ladder is not allowed. For elevation higher than 12ft. side step scaffold is required.

YNN/ASafety Officer designated to the area.YNN/AFire blanket/welding screen for welding, cutting/grinding works provided.

YNN/ASafe Work Plan submitted alongside with elevated work permit.YNN/AElevated work will not be performed above fuel driven equipment.

YNN/AProper and adequate housekeeping is maintained.YNN/AElevation Work has safe access and egress and secures anchor points.

Section C: AUTHORIZATION TO PROCEED WITH ELEVATED WORK

This is to certify that the above criteria are satisfactorily met and related work permits and safe work plans are completed.

TASK SUPERVISOR/G.FOREMAN/FOREMANNAME (Please Print):

SIGNATURE: DATE:

SITE ENGINEERNAME (Please Print):

SIGNATURE: DATE:

APPROVED BY:

AREA SAFETY SUPERVISOR/SITE SAFETY SUPERVISORNAME (Please Print):

SIGNATURE: DATE:ZONE MANAGER/PROJECT ENGINEER/LEAD ENGINEERNAME (Please Print):

SIGNATURE: DATE:

Section D: EXTENSION OF WORK PERMIT

REQUEST BY:TASK SUPERVISORNAME:

SIGNATURE:SITE ENGINEERNAME:

SIGNATURE:DATE/TIME EXPIRES:MANPOWER

APPROVED BY:AREA SAFETY SUPERVISOR:NAME:

SIGNATURE:SAFETY SUPERVISOR:NAME:

SIGNATURE:ZONE MANAGER/PROJECT ENGG/LEAD ENGGNAME:

SIGNATURE: