GCC- SHAFT WORK PERMIT
STOP! Before starting Shaft work activities review all safety precautions.
Can this work be avoided or is there a safer way, even so, do not authorize work!
Project: (01-17) Stella Maris Tower Date of issue: Permit number:
General Construction Company Sub- contractor (Name):
Location (Specific Area Name & Room # and/or Exterior Location):
Name of person incharge of work
Floor / Shaft no.
Scope of work (Description of task, how many men going to work) Total no. of person going to
Electrical, Mechanical, Fire, Lift, work
Other___________________
Description of work: EMERGENCY CONTACT NUMBER
(In case of an emergency please call) – 0565399167
S. Check Points Ye N If No, what control measures are put in
n s o place
o
1. Is there Method of statement and risk (If No, Work is not permit to start)
assessment in place?
2. Are all any person working either above or
below and protected from falling objects?
3. Is the access to slab clear to safe?
4. Is the working platform fully boarded out with
planks and secured?
5. Has the working platform all guard rails and
toe boards in place?
6. Is there good lighting (100 lux) within shaft for
work?
7. Is there good ventilation within the shaft?
8. Has entry to the shaft been protected to stop
unauthorized personnel entering the shaft?
9. Have all open edges secured with the edge
protection?
10. All person going to work in shaft are
competent?
Additional Precaution (if any)
Mandatory PPE required
1. Performer’s Acknowledgement: 2. Supervisor Acknowledgement:
I understood the work that is to be carried out and will ensure the above mentioned I will monitor the work that is to be carried out and will ensure the above mentioned necessary
necessary safety precautions are followed at all times, I will complete my task in safe safety precautions are followed at all times, I will complete this task in safe method and I accept
method and I accept responsibility for this work. responsibility for this work.
Name: Name:
Performer Supervisor
(Permit Receiver) (Permit Receiver)
Signature: Signature:
3. Checked and approved by Acknowledgement: 4. EHS Department Acknowledgement:
Authorization is hereby granted for the works as described above. I have checked above control measures and the work area is safe to carry out the activity.
SAFE TO WORK UNSAFE TO WORK
Concerned Engineer Name:
(Permit Issuer) Safety officer
Signature: Name:
Permit Validity Period (Time): From: To: Signature:
GCC- EHS- SWP-50-Rev.03_03032022
GCC- SHAFT WORK PERMIT
STOP! Before starting Shaft work activities review all safety precautions.
Can this work be avoided or is there a safer way, even so, do not authorize work!
Project: (01-17) Stella Maris Tower Date of issue: Permit number:
General Construction Company Sub- contractor (Name):
Location (Specific Area Name & Room # and/or Exterior Location): Name of person incharge of work
Floor / Shaft no.
5. Closed Out:
This is to certify that the works described above have been safely completed / stopped / area has been restored to a safe and orderly condition.
Name: Name:
Concerned Engineer
Signature: Safety officer
(Permit Issuer) Signature:
Closed Out Time:
GCC- EHS- SWP-50-Rev.03_03032022
