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Work Permit

This document is a general work permit form for work at PT. PLN (Persero) UPP KITRING KBB 4. It provides details about the work including location, duration, equipment used, type of work, required preventative actions and safety measures, required personal protective equipment, and required documents to be submitted. The form requests information such as work description, project manager contact details, number of workers, work classification (e.g. at heights, confined spaces), safety procedures to follow before and after work, and other safety instructions. Completing this form allows the project owner/representative to issue a permit number for the specified work.

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Biyan Yoga
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4K views3 pages

Work Permit

This document is a general work permit form for work at PT. PLN (Persero) UPP KITRING KBB 4. It provides details about the work including location, duration, equipment used, type of work, required preventative actions and safety measures, required personal protective equipment, and required documents to be submitted. The form requests information such as work description, project manager contact details, number of workers, work classification (e.g. at heights, confined spaces), safety procedures to follow before and after work, and other safety instructions. Completing this form allows the project owner/representative to issue a permit number for the specified work.

Uploaded by

Biyan Yoga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Work Description: Contains fields for detailing work description, general details about the work being performed, and equipment used.
  • Preventive Action Before & After Work: Outlines preventive measures and safety actions required before and after performing the work.
  • Approval of Work: Includes sections for approving the work, acknowledgment by supervisors, and final work completion details.

PT.

PLN (Persero)
FORMULIR IZIN KERJA UMUM/
UPP KITRING KBB 4 GENERAL WORK PERMIT FORM

Safety Management System Doc. No : Rev. No :


Page 1 of 3 Date Rev :

Nomor izin/ ( Nomor ini diisi oleh pemilik proyek/perwakilan / This number filled by project
/GWP/PB/F-HSE/20
Permit Number owner/representative)

Tanggal pengajuan/
Date submissions
URAIAN PEKERJAAN*/
WORK DESCRIPTION*
Nama pekerjaan/
Work name
No.SPK/Kontrak/Memo
No.WO/Contract/Memo
Departemen / Devisi
Department / Devision
Instansi / Nama perusahaan
Phone.
Instance / Company name
Nama manager proyek/
Phone.
Project manager name
Area / Lokasi kerja
Area/ work location
Lama pekerjaan/
............. Hari/Days ............................................... Sampai / to ................................................
Duration work days
Waktu Kerja Per Hari/
............. Jam/Hours .......................... Sampai / to .................................
Working time per day
Nama pengawas lapangan/
Phone.
Field Supervisor name
Jumlah pekerja/
............. Orang/Person
Total of workers
 Peralatan tangan / Hand  Alat berat/Alat angkat /  Mesin berputar/Bergerak /
tools Heavy equipment/Lifting Machine spinning / moving
 Truk/Trailer / Trailer/Truck equipment  Peralatan Listrik / Electric
PERALATAN YANG  Bucket/Keranjang orang /  Kompresor / Compressor Equipment
DIGUNAKAN/ Man baskets/Bucket  Pompa portable / Portable  Welding machine / Welding
EQUIPMENT USED  Perancah / Scaffolding pump machine/Pressure cylinder
 Vakum / Vacuum  Alat Pengetesan / Tester  Lain-lain/Other .................
 Genset / Generator equipment ..........................................
 Pengaduk / Mixer

JENIS DAN KLASIFIKASI PEKERJAAN*


TYPE AND CLASSIFICATION OF JOB*
 Bekerja dibawah kabel listrik / Daerah  Bekerja di ketinggian >2 Mtr / Working  Penggalian / Excavation
bertegangan listrik tinggi / Works under at height >2 Mtr  Fabrikasi / Fabrication
power line / High-voltage electrical  Konstruksi / Construction  Pemancangan / Piling
area  Inspeksi / Pengecekan / Inspection /  Pengecatan/Sandblasting/
 Pemasangan / Perakitan komponen Checking Painting/Sandblasting
listrik / Installation / Assembling of  Radiografi / Radiography  Transportasi/Pengepakan/
electrical components  Ruang terbatas / Confined space Transportation / Packaging
 Instrumentasi / Instrumentation  Pengelasan/Kerja panas / Welding/Hot  Perawatan/Reparasi/
 Penyambungan / Supply Connection work Repair/Maintenance
 Tali-temali & Pengangkatan / Rigging &  Pengujian/Komisioning / Testing /  Kerja tambahan/lembur/
Lifting Commissioning Work additional/Overtime
 Isolasi / Isolation  Penanganan Limbah Kimia (B3) /  Lain-lain / Other ..........................
 Perpipaan / Piping Chemical Waste Treatment (Hazard ....................................................
Material)

*Harap data dan keterangan pada formulir ini diisi secara manual/Please the data and details on this form are filled manually
PT. PLN (Persero) FORMULIR IZIN KERJA UMUM/
UPP KITRING KBB 4 GENERAL WORK PERMIT FORM

Safety Management System Doc. No : Rev. No :


Page 2 of 3 Date Rev :

TINDAKAN PENCEGAHAN SEBELUM & SETELAH BEKERJA* /


PREVENTIVE ACTION BEFORE & AFTER WORK*
 Proteksi/Perangkat anti jatuh /  Sertifikat kompetensi / Certificate of  Sertifikat alat / Equipment certificate
Protection/Anti fall device competence  Tali pengaman / Pegangan tangan /
 Pemadam api / Fire extinguisher  Mengikuti syarat HIRAC / JSA / Safety ropes / Handrail
 Selimut penghambat api/Percikan / Fire Following HIRAC / JSA requirements  Pagar / Barikade / Fences / Barricades
blancket / Spark  Memasang rambu keselamatan /  Orang yg menerima/memberi aba-aba /
 Pelantar / Platform Peringatan / Pelabelan / Install safety Signalman
 Tangga / Ladders signs / Warning / Labeling  Lain-lain/Other ..............................
 Terpal / Penutup / Tarpaulins / Cover  Pembersihan / Housekeeping ......................................................

TINDAKAN KESELAMATAN YANG LAIN DIPERLUKAN*/


OTHER SAFETY MEASURES ARE REQUIRED*

Harap mengikuti / Please follow:


 UU No. 1 Tahun 1970 / Law of Indonesian Republic Number 1/1970
 Peraturan : Menteri, Presiden dan pemerintah daerah / Regulations: Ministers, Presidents and local governments
 Metode kerja aman & HIRAC/JSA / Safe working methods & HIRAC / JSA
 SOP dan aturan proyek yang diberlakukan / Applicable standards operating procedure and project rules
 Dokumen Kontrak/ Surat keputusan / Contract Document/ Decree
 Standar indonesia atau standar internasional yang diberlakukan / Indonesian standards or international standards are enforced

Instruksi lainnya / Other instruction :

ALAT PELINDUNG DIRI YANG WAJIB DIGUNAKAN*/


PERSONAL PROTECTIVE EQUIPMENT THAT MUST BE USED*
 Helm / Helmet  Sarung tangan katun / Cotton gloves  Pelindung tubuh / Full body harness
 Kacamata / Safety Glasses  Sarung tangan karet / Rubber gloves  Rompi keselamatan / Safety Vest
 Sepatu Pelindung / Safety shoes  Masker / Mask  Cap pengelasan / Welding cap
 Sepatu Karet / Rubber boots  Respirator / Self Contained Breathing  Celemek / Apron
 Pelindung pendengaran/ Hearing Apparatus (SCBA)  Lain-lain/Other ...........................
protector / Ear Plug / Ear muff  Seragam penuh / Wearpack
LAMPIRAN / DOKUMEN YANG HARUS DISAMPAIKAN*/
ATTACHMENTS / DOCUMENTS TO BE SUBMITTED*
 Prosedur Uji Inspeksi / ITP (Inspection  Metode Kerja / SOP / Work  Data lembaran bahan berbahaya /
Test Procedure) methode/SOP MSDS
 Gambar Kerja / Work drawing  Spesifikasi : Produk/peralatan /  Dokumen lainnya (jika diminta) / other
 Identifikasi penilaian & pengontrolan Specifications: Product / equipment document (if requested)
bahaya/ HIRAC/JSA
Catatan / Note : Seluruh kelengkapan dokumen akan diperiksa oleh pemilik / perwakilan proyek / All documents will be checked by
the project owner / representative

*Harap data dan keterangan pada formulir ini diisi secara manual/Please the data and details on this form are filled manually
PT. PLN (Persero) FORMULIR IZIN KERJA UMUM/
UPP KITRING KBB 4 GENERAL WORK PERMIT FORM

Safety Management System Doc. No : Rev. No :


Page 3 of 3 Date Rev :

PERSETUJUAN PEKERJAAN*/
APPROVAL OF WORK*
Pemohon Izin Kerja/
Work Permit Applicant
Pemilik / Perwakilan Proyek,
Project owner / representative

( .......................................... )
Field Supervisior
Diperiksa oleh/
Checked by,

( .......................................... ) ( ................................ ) ( ................................ )


HSE Officer - Contractor HSE Rep – PLN UPP KITRING KBB 4
Date : Date : Date : Date :

Pastikan Petugas K3 dari perusahaan/kontraktor yang mengajukan izin kerja memeriksa terlebih dahulu seluruh kelengkapan dokumen
sebelum diajukan ke pemilik/perwakilan proyek / Ensure the Occupational Safety Officer of the company/contractor applying for a work
permit shall first check all the completeness of the documents before submitting to the project owner / representative

PENYELESAIAN PEKERJAAN*/
WORK COMPLETION*
Pekerjaan telah selesai pada Disampaikan Oleh/ PLNE Supervision Construction/
tanggal / Work completed on : Submitted By : PLN UPP KITRING KBB 4
Date :

Time:
Name & Sign: Date : Name & Sign : Date :

Tembusan / Copies :
- Penanggung jawab pekerjaan/ Person in charge of work
- Supervision Construction (HSE)
- PLN UPP KITRING KBB 4

*Harap data dan keterangan pada formulir ini diisi secara manual/Please the data and details on this form are filled manually

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