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General Work Permit Form Template

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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86% found this document useful (7 votes)
2K views3 pages

General Work Permit Form Template

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
  • Preventive Action Before & After Work
  • Approval of Work

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
[Link]/Kontrak/Memo
[Link]/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

Common questions

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Jobs involving high-risk areas such as working under power lines or at heights typically require safety equipment including protective helmets, safety harnesses for fall protection, and possibly scaffolding or ladders to perform tasks safely. Additional tools might include anti-fall devices, proper clothing like safety vests, and specific safety signs to alert workers and passersby of ongoing high-risk activities .

Having documents checked by the Occupational Safety Officer before submission is crucial to ensure that all safety protocols and preventive measures have been adequately addressed. This pre-submission check serves as a quality control measure to ensure that all stipulated regulations and safety requirements are met, reducing the risk of hazards during the execution of work .

Signalmen play a crucial role in ensuring safety, particularly in environments where clear communication is essential to prevent accidents. They provide visual or audible signals to guide operations involving heavy machinery, reducing the risk of collisions or miscommunication among workers. Their presence is essential in maintaining a coordinated and safe workflow, especially in complex or congested work areas .

The form ensures compliance with safety standards and regulations by requiring adherence to various regulations, including Indonesian laws such as UU No. 1 Tahun 1970, and directives from ministers and local governments. It also mandates following safe working methods, HIRAC/JSA, applicable standard operating procedures, and project rules. These measures are designed to enforce both Indonesian and international standards .

The General Work Permit Form records the work duration and scheduling by documenting the specific number of workdays and the hours of work per day, including start and end times. This detail helps in planning and monitoring the project's timeline, ensuring that tasks are completed within the allocated time and reducing the risk of schedule overruns .

Several preventive actions required before and after work include using protection or anti-fall devices, having fire extinguishers ready, utilizing fire blankets or spark covers, setting up platforms, ensuring ladders are available, and implementing covers such as tarpaulins. The form also advises following HIRAC/JSA requirements, installing safety signs, and maintaining cleanliness .

Failure to use appropriate personal protective equipment (PPE) can lead to severe injuries or fatalities, particularly in high-risk work environments. Without items like helmets, safety glasses, or body harnesses, workers may be vulnerable to head injuries, eye damage, or falls. Adhering to PPE requirements minimizes exposure to occupational hazards and ensures compliance with safety regulations .

Attaching documents like the MSDS (Material Safety Data Sheet) or equipment certificates is significant as they provide detailed safety information about the materials and tools being used, ensuring that any potential hazards are well-documented and understood. This documentation is critical for maintaining a safe work environment and ensuring that personnel handling these materials or equipment are aware of and equipped to manage any associated risks .

Safety signs and labeling are critical components of workplace safety as they serve to inform and alert workers of potential hazards, ensure compliance with safety standards, and guide safe practices on site. By clearly indicating hazardous areas or equipment, they help prevent accidents and promote a culture of safety awareness .

The project owner or representative is responsible for reviewing and approving the work permit application, ensuring all safety measures and documentations are accurately completed. They must verify compliance with the stipulated standards and safety regulations, demonstrating accountability for both the safety and legality of the project tasks. This role includes checking completeness of documents submitted by the contractor's safety officer before work can commence .

FORMULIR IZIN KERJA UMUM/ 
GENERAL WORK PERMIT FORM 
Safety Management System 
 
Doc. No :  
Rev. No :  
Page 1 of 3 
D
FORMULIR IZIN KERJA UMUM/ 
GENERAL WORK PERMIT FORM 
Safety Management System 
 
Doc. No :  
Rev. No : 
Page 2 of 3 
Da
FORMULIR IZIN KERJA UMUM/ 
GENERAL WORK PERMIT FORM 
Safety Management System 
 
Doc. No :  
Rev. No : 
Page 3 of 3 
Da

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