PSS-FRM-L-400-005 PTW Land Hot Work

LAND PERMIT FORM : HOT WORK
Permit to Work Office No.: Emergency Contact No.: 800112
If the conditions or procedures specified on this permit change, Applicant shall STOP WORK IMMEDIATELY, and notify the Permit to Work
Office / Permit Issuer
NOTE: To be submitted along with PSS-FRM-L-400-001 (Land Permit Application)
Permit No. Work Order/ Contract No.
Date Date
Job Expir
Port Name:
Start y
Time Time
Permit Work Location &

Description
No. of Workers No. of Supervisors
HAZARD IDENTIFICATION
Work to be Performed
 Electrical and gas welding  Heat treatment or stress relieving of piping

 Cutting, grinding, brazing  Operating of internal combustion engine
 Use of any tools/portable equipment that can produce
 Grit, sand, or other abrasive blasting sparks/heat or use of hot tapping equipment
 Use of any electrical equipment not meeting the
 Breaking concrete specification for the classified hazardous area (cell
phones, flash cameras, radios, etc.)
 Chipping  Other, specify:
For Hot Work in Enclosed/ Confined Space, PSS-FRM-L-400-002 PTW Land Confined Space Entry Form shall be
attached
Description of work to be Performed
Hazardous Materials located and/or brought into Operation
Major Equipment located or to be brought into Operation
CHECK ALL POTENTIAL HAZARDS/ RISK IMPACTS AS APPLICABLE:
 Flammable gases, vapors  Temperature extremes  Overhead activities

 Ignition potential (such as, naked flame,
 Falling objects  Failure of Mechanical equipment
sparks)
 Hot welding  Noise  Moving equipment (or parts)
 Smoke  Electrocution  Engulfment
 Pressurized hose failure  Slip, trip and fall  Radiation
 Pressurized gas cylinder failure  Poor visibility  Entry and exit limitations
 Uncontrolled introduction of steam, gas,
 Drowning  Tripping hazard
or liquid
Other Anticipated Hazards

(describe below)
© 2016 AD PORTS, Abu Dhabi, United Arab Emirates PSS-FRM-L-400-005, Rev.2 (1Jan2016) AD Ports HSE
Page 1 of 4
RISK CONTROLS (check as ‘Yes’ or ‘No’ or ‘NA’ as appropriate; add rows (Yes /No
Remarks
as required) /NA)
Dust, lint, debris, flammable/ combustible liquids and oily

1.
deposits removed.
2. Explosive atmosphere in area eliminated.
Flammable/ combustible material removed, where possible; or
3.
protected with fire blankets, guards, or metal shields.
While working on walls/ ceilings, combustibles material moved
4.
away from other side of wall.
5. Walkways protected beneath hot work.
Hot Work in Confined Spaces:
Acted in accordance with Confined Space Entry Procedure;
6.
PSS-FRM-L-400-002 Form is attached.
Watching the Hot Work Area: (by the Fire Watch)
Competent Fire watch will be provided during and for 30 minutes
7.
after work, including any coffee or lunch breaks.
Fire watch may be required for opposite side of walls, above,
8.
and below floors and ceilings.
Relevant Administrative & Engineering Controls:
Act in accordance with AD EHS RI- CoP- 28.0 “Hot Work
9.
Operation”
Hot Work Equipment in good condition (e.g., power source,
10.
welding leads, torches, etc.)
11. Sprinklers and hose streams in service/ operable.
12. Multi-purpose fire extinguisher and/or water pump available.
ADDITIONAL HSE PRECAUTIONS, IF YES LIST THEM
Check required emergency equipment:
 Fire extinguisher (type?)  Life line/retrieval line
 Emergency shower / eyewash  Tripod and mechanical winch
 PPE (including, Safety harness, coveralls, steel toe boots,

hard hat, safety goggles, face shields, gloves, hearing  Two-way communication equipment (radio, etc.)
protection)
 Breathing apparatus (BA, SCBA, etc.)  Source of forced/natural ventilation
 Gas detectors  Emergency exits clear?
 First aid kit  Other (specify)
PTW APPLICANT DETAILS:
Company Name
Company Contact
Fax No.
No.
Email Address:
Permit Applicant
Contact No. Email
Permit Receiver
Page 2 of 4
Contact No. Email
Page 3 of 4
PTW APPROVAL ( AD PORTS USE ONLY )
This Permit to Work is issued for the above work and locations ONLY and ONLY on the condition that all
required documentation (e.g. risk assessment) and permits have been completed and the requirements
thereof communicated to all involved persons.
Name Signature & Date Contact No.
Permit Applicant
AD Ports Permit to Work Office
Permit Issuer
Conditions:
1. Permit valid within the work location only.
2. In case of emergency, contact Permit to Work Office & AD Ports Control Room: 800112
3. All completed Permits must be returned to AD Ports Permit to Work Office to enable closure of this permit.
4. This form shall be printed in one sheet (Front & Back).
Page 4 of 4

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LAND PERMIT FORM : HOT WORK

Permit to Work Office No.: Emergency Contact No.: 800112

NOTE: To be submitted along with PSS-FRM-L-400-001 (Land Permit Application)

Permit No. Work Order/ Contract No.

Permit Work Location &

No. of Workers No. of Supervisors

 Electrical and gas welding  Heat treatment or stress relieving of piping

Description of work to be Performed

Hazardous Materials located and/or brought into Operation

Major Equipment located or to be brought into Operation

CHECK ALL POTENTIAL HAZARDS/ RISK IMPACTS AS APPLICABLE:

 Flammable gases, vapors  Temperature extremes  Overhead activities

 Smoke  Electrocution  Engulfment

 Pressurized hose failure  Slip, trip and fall  Radiation

Other Anticipated Hazards

Permit to Work Office No.: Emergency Contact No.: 800112

Dust, lint, debris, flammable/ combustible liquids and oily

ADDITIONAL HSE PRECAUTIONS, IF YES LIST THEM

Check required emergency equipment:

 Fire extinguisher (type?)  Life line/retrieval line

 Emergency shower / eyewash  Tripod and mechanical winch

 PPE (including, Safety harness, coveralls, steel toe boots,

 Breathing apparatus (BA, SCBA, etc.)  Source of forced/natural ventilation

 Gas detectors  Emergency exits clear?

 First aid kit  Other (specify)

PTW APPLICANT DETAILS:

Contact No. Email

Permit to Work Office No.: Emergency Contact No.: 800112

Contact No. Email

Permit to Work Office No.: Emergency Contact No.: 800112

PTW APPROVAL ( AD PORTS USE ONLY )

Name Signature & Date Contact No.

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