Daily Safe Work Permit

SECTION A: GENERAL INFORMATION

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Septa Apple Matton Deno MP JP
Date: 26 September Project Name & # Bulk Barn Division: Demolition Supervisor: Oscar Samuel Permit Writer:

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Description of Work: Scope Of Work/Location:

SECTION B: EMERGENCY INFORMATION

No Flooring No ceiling Millwork contents
Muster/Assembly Point: Designated First Aid Attendant: Alternate First Aid Attendant: JHSC Worker Rep (if req’d):
Paola Navarro

Kingsway Ext
INCIDENTS, SAFETY ALERTS, NEAR MISSES AND/OR HAZARD I.D.’S: MP 58
SECTION C: ADDITIONAL PERMITS AND SAFE WORK PLANS and PROCEDURES (check all that apply)
☐ Lockout/Tagout- Hazardous Energy Control Plan ☐ Hot Work Permit ☐ Confined Space Entry Permit ☐ Lift Plan (i.e. critical) ☐ECP -Exposure Control Plan ☐ Env’tl Control/Pollution Plan
☐ Fall Protection & Rescue Plan ☐ Excavation Checklist ☐ Defeat Critical Safety Permit ☐ Fatigue/ Journey [Link] ☐ RA – Risk Assessment ☐ Emergency Response Plan
SECTION 4: HIGH RISK CRITICAL TASKS BEING PERFORMED that require review of JSAs/SWPs/SOPs/WIs ritical)

X
ISSUES/CONCERNS? New Workers/Green Hands? Yes/No
Heavy lifting
SECTION D - HAZARD IDENTIFICATION (check all that apply)
Biological Chemical Physical Ergonomic Psychosocial
☐Blood borne Pathogens ☐Inhalation ☐ Radiation ☐ Line of Fire (Caught By/Struck By) ☐ Working in tight area ☐ Stress
☐ Pandemic/Endemic ☐Skin Contact/Absorption ☐ Hazardous Energy ☐ Pinch points ☐ Congested work area ☐ Violence/Harassment
☐ Dust ☐Ingestion ☐ Confined Spaces ☐ Air quality ☐ Working above head height ☐ Civil Unrest (protests)
☐ Bacteria, Mold, Fungi ☐Chemical Burn (eyes/skin) ☐Excavations ☐ Over/Underground Obstructions ☐ Repetitive motion ☐ Other:
☐Plant/Insect/Animal ☐Spill ☐ Temperature Extremes ☐ Uneven walking surfaces ☐ Awkward Posture
☐Wildlife ☐Fire/Explosion (hot/cold) ☐ Sensitive Equipment in area ☐ Heavy Lifting ☐ Weather Conditions:
Type of Wildlife?: ☐Compressed Gas ☐ Pressure Extremes ☐ Limited Access/Egress ☐ Inadequate Lighting ☐ Other site hazard not listed above:
☐Hazardous Materials (high/vacuum) ☐ Work at Heights ☐ Shift Work
Type? ☐ Noise
☐ SDS for Hazmat are available ☐ Slip/trip Hazards
☐ SDSs have been reviewed

SECTION E – EQUIPMENT & TOOLS (check all that apply)

☐ Ladder (always the last option & only used if permitted) ☐ Scaffold ☐ PEWP/EVP ☐ Crane ☐ High Reach ☐ Lift Truck ☐Excavator ☐Mini Excavator

☐ Generator ☐ Vac Truck ☐ HEPA Vacuum ☐ Power ☐ Skid Steer ☐ Bulldozer ☐ Rock Truck ☐Other:Click or tap here to enter text.
☐ Hand Tools ☐Power Hand Tools Washer in use of tool/equipment
☐Trained ☐Pre-use inspection complete

SECTION F – PPE - PERSONAL PROTECTIVE EQUIPMENT (check all that apply) Mandatory on All Jobsites - Hard Hat, Safety Glasses, Hi-Vis Vest, Long Pants, Safety Boots
Eyes Ears Hands & Arms Respiratory Foot Body-Trunk Other
☐ Goggles ☐ Ear Plugs ☐ Glove-Leather ☐ Glove Other: ☐ Full Face ☐Metatarsal Protection ☐ FRC ☐ Rain Suit ☐Arc Flash Protection
☐ Face Shield ☐ Earmuffs ☐Glove-Rubber Type: ☐ Half Face ☐ Toe Caps ☐ Tyvek ☐ Apron ☐ Fall Protection
☐ Welding Mask ☐ Double ☐ Glove-Nitrile ☐ Long Sleeves ☐ Cartridge: Type ☐ Rubber ☐ Chemical Resistant Apron Type? ☐ Reflective Arm & Leg Bands
☐ Hard hat liner ☐ Glove Neoprene ☐ Arm Guards ☐ Filter Type?: ☐ Other: Type of Suit: ☐ PFD – Personal Flotation Device
☐ Glove – Kevlar Other Type ☐ Chaps/Leathers ☐ Other:
☐ Glove - Welding ☐ Other: Type: ☐ Dust Mask (N95)
☐ SCBA/Supplied Air

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Daily Safe Work Permit (EHS-F-3-04/FORM 3.4)/2022-07-26 Page 1 of 2
 Daily Safe Work Permit Boffroagere
SECTION G – JOB HAZARD ASSESSMENT
# JOB TASK SEQUENCE / PROCEDURE / STEP-BY-STEP HAZARD(S) CONTROL(S)
(Choose from hazards identified above) (Apply hierarchy of controls Elimination, Substitution,
Isolation/Engineering Controls, Administrative Controls (i.e. training,
SWPs, JSAs procedures etc. and PPE)

Content removal
1

Heavy lifting bend with knees

Levelling compound removal ' Heavy lifting Lift with knees

2
Task rotation

Selective Demo Cuts pinchpoints

Mortar removal

gloves glasses proper

Repetitive motion

useof tools
Content manipulation Ergonomics Active pauses

5
Floor removal euganemics cuts proper
use
of chipping
gun
You MUST set time intervals here to review DSWP throughout the day (re-assess hazards/controls after breaks, when conditions, crew size, weather, process, and work scope change. Communicate if there are any
changes): Personnel must re acknowledge by initialing beside their signature below.
Example: After break – 10AM/ 1PM/ 4PM

Review this permit with all crew members, other persons nearby or entering work area that hazards may impact. By signing this DSWP you agree that:
 You are fit for duty, have reported all personal injuries, discomfort/pain, current medications that may affect your ability to perform your work today with the site Supervisor and/or the EHS department.
 You have inspected all personal PPE and it’s in good working condition.
Print Name Signature Review Interval & Acknowledgement
(to be added upon initial review)
State Time Review Interval & Initial to Acknowledge Review

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Time Reviewed? Initials Time Initials Time Initials
Reviewed? Reviewed?

Jun PabloDeming
Oscar Samuel

Spt 11 43pm
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PaolaNavarro Dr Spath 930pm MP

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Rafael Mayen t
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Supervisor / Foreman Name & Signature: Management Field Review Name and Signature:

Daily Safe Work Permit (EHS-F-3-04/FORM 3.4)/2022-07-26 Page 2 of 2