Night and Holiday Work Permit

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Out of Hours /Extended Hours/ Night Works / Holiday Work Permit

Permit to Work No: Location/ Area:


PART 1. DETAILS OF THE CONTRACTOR REQUIRING TO DO WORK AFTER NORMAL WORKING HOURS:
Contractor Name: Date:
Contact Name: Contact No:
(Construction Manager)
Signature:
Emergency Contact: Contact No:
(Person Name)
Job Title: Signature
PART 2. DETAILS OF PERIODS REQUIRED FOR WORK AFTER NORMAL HOURS:
After working hours timing: Person Name
Start Date _____/_________ /_________ Start Time: ____ : _____ In Job Title
Charge
End Date _____/_________ /_________ End Time: ____ : _____ Signature:
PART 3. DETAILS OF WORKS TO BE CONDUCTED AFTER NORMAL HOURS:
General Construction Material Handling Commissioning & Testing Transport
Maintenance Office / Clerical Others (specify)
PART 4. DETAILS OF HSE PRECAUTIONS FOR WORKS TO BE CONDUCTED AFTER NORMAL WORKING HOURS:
Indicate all the basic HSE precautions that will be in place for above listed works by marking the appropriate blocks below
with "X" noting that all items marked "YES" must be available for inspection at work.
Confirm Yes No N/A Confirm Yes No N/A
DSTI Form Completed MS/RA Approved
HSE Officer First Aider
Fire Fighting Equipment Emergency contact numbers displayed
Warning Signs and barricade in place Warning Lights
Noise Controls PPE for all staff
Hot Works (with valid hot work permit) Power tools with valid dispensation
Transport Night Shift Work Trainig/ Induction
Site Security precautions in place Risk Assessed for Night works
First Aid Equipment Training Records
Access and Egress Routes demarcated Illumination (meeting task specific lux)
All illumination facing away from All other plant and equipment
Avaiation operations registered, certified and inspected
Other Other
PART 5. NIGHT SHIFT / HOLIDAY WORKS PERMIT ACKNOWLEDGEMENT:
Site Engineer/ Site Management Site / Construction Manager HSE Officer/ HSE Management

(Print Name of person submitting) (Print Name of person reviewing) (Print Name of person reviewing)

(Comments) (Comments) (Comments)

(Gardinia Site Engineer Signature & Date) (Gardinia Site Manager Signature & Date) (Gardinia HSE management Signature & Date)
*Normal working hours for site works are within the period of 07:00 to 17:00 daily from Monday to Saturday as per GBC normal work timings.
**This form is only valid if Part 5 has been signed by all four indicated parties.
**On nights and holidays, no hot work activities will be permitted..

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