COMPANY NAME & LOGO

PROJECT
PERMIT TO WORK – LIFTING Form No:
Applicable to any lifting operations.
Validity of Permit: 24 Hours ONLY -This Permit is to be displayed at work area upon approval.
Trade
Company :
:
Location :
(To attach site layout plan if
any )

Purpose :

Mode of Mobil Towe Crawle Lorry Chain Lever

e r r Crane Block Block Others:______________________________
lifting: __
Crane crane Crane s s
Mode of Work: SINGLE LIFT MULTIPLE LIFTING
LIFT MORE THAN
15 TONS

Date of
Time from: Time to:
Commencement:
Name of Contractor’s Contact No.:
Supervisor in Charge:
Name of Contractor’s Contact No.:
Lifting Supervisor:

Name of Rigger Signature :

Name of Signaller Signature :

SAFETY REQUIREMENT
No. Description YE N NA Remarks
S O
1 RISK ASSESMENT AND SAFE WORK PROCEDURES GENERATED AND COMMUNICATED TO THE WORKERS PRIOR THE
COMMENCEMENT OF WORK

2 DAILY OPERATIONAL CHECK PERFORMED BY CRANE OPERATOR / APPOINTED PERSON:_________________________________?

3 CORRECT TYPE OF LIFTING GEARS USED?

LG and LA IN GOOD CONDITION, FREE OF DEFECTS AND WITH VALID MOM CERTIFICATE?

4 OUTRIGGER IS FULLY EXTENDED ON STEEL PLATE?

IS SUFFICIENT STEEL PLATE PROVIDED AND ARRANGE PROPERLY BELOW THE CRANE?

5 IS THE CRANE PARK ON FIRM STABLE GROUND?

CRAWLER TRACKS IN GOOD CONDITION?

6 PROPER HOOKS OR LIFTING POINTS PROVIDED ON MATERIALS TO BE LIFTED AND TAG LINE PROVIDED?
Confirmed By:
7 IS THE RIGGER / SIGNALLER ARE CERTIFIED AND COMPETENT TO SAFELY PERFORM THE LIFT AND THE EQUIPMENT (Name &
DESIGNATED Signature)

8 THE LOAD WEIGHT, CENTRE OF GRAVITY FOR THE LIFT HAS BEEN ACCURATELY CONFIGURED?

9 AFFECTED AREA IS CLEAR OF OBSTRUCTION THAT MIGHT HINDER THE LFTING WORKS Subcon PM or
Subcon Safety
Date :
10 MONTHLY MAINTENANCE INSPECTION STICKER VALID? Time :
COLOUR CODE OF THE MONTH VISIBLE?
I have read the above conditions and will comply strictly with the requirements and ensure workers under my charge will comply too. I shall brief them
daily before start of work. I fully understand that if there any changes to the condition, the permit shall be considered void. A fresh permit will have to be
re-applied.
Complied Acknowledged Reviewed by Reviewed by Endorsed by Approved Final
by by (Name & Signature) (Name & Signature) (Name & Signature) (Name & Signature)
by Approval
(Name & (Name & (Name & Signature)
Signature) Signature)
Day Day Day

Night Night Night

Contractor Supervisor in Manager Construction

Lifting Charge Manager Safety Project [Link]
Supervisor in Department Manager Manager
Charge
Date: Date: Date: Date: Date: Date: Date:
Time: Time: Time: Time: Time: Time: Time:
NOTIFICATION OF WORK COMPLETION / RENEWAL * BY LIFTING SUPERVISOR *DELETE WHERE APPLICABLE

Published By Champion Management Services Pte Ltd | +65 6774 2949 | hr@[Link]
COMPANY NAME & LOGO
Work Completed / at Hours
Renewal* on (DATE) (TIME)

Name of Contractor’s : Signature :

Supervisor in Charge
Revision Issued Date Page :
: :

RECORDS OF WORKERS INVOLVING WITH PTW

Validity of Permit: 24 hours
To be displayed and attached together with the permit

Company : Date :
S/n Name Designation Signature

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Declaration from the Supervisor in-charge :

I have briefed the above workers on the RISK ASSESSMENT AND SAFE WORK
PROCEDURES related to the specific work involved at height. I shall supervise the
workers and ensure they abide with the SITE SAFETY REQUIRMENTS at all times.
Conducted by Witnessed by
(Name & Signature) (Name & Signature)
Day Day

Published By Champion Management Services Pte Ltd | +65 6774 2949 | hr@[Link]
COMPANY NAME & LOGO
Night Night

Contractor’s Lifting Supervisor in charge Contractor’s Safety Supervisor in Charge

Date: Date:
Time: Time:
Revision Issued Date Page :
: :

Published By Champion Management Services Pte Ltd | +65 6774 2949 | hr@[Link]