ASAK HSE DEPARTMENT

LIFTING OPERATION : WORK PERMIT

1. Project Information: ,Marsa al Arab, Al Khan, Sharjah
Project Name/No: Permit No.:
Project Location:
Requesting Contractor/Company Al Serh Al Kabeer / (specify if other company)

Description of Task:

Detail of Surroundings:

2. Permit Issuance Details: (To be filled by initiator/originator)

Initiator/ Originator:
Contact:
(SE/GFM/FM/CH)
Evaluator: (HSE Team) Contact:
Approving Authority:
Contact:
(PM/DPM/SA)

Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:

Weight of Load : Max Height of Lift:
Max. Radius of Lift:
Lifting Point Defined: Yes No Road Closure/ Isolation required: Yes No
Underground services: Yes No Load Centre of Gravity Calculated: Yes No

3. Lifting Operation Details: (To be filled by initiator/originator)

Crane Operator Contact:
Rigger-1 Contact:
Rigger-2 Contact:
Type of Lifting Crane: Mobile Crane Elevated working Platform
Wheel crane Crawler Crane Telescopic truck
All Terrain All Winch
Tower Crane Other :
Excavator/ Backhoe
Lifting Crane Specification: Year of make (<25 years): SWL:
Lifting Capacity: Boom Reach:
Fly Jib Reach:
No. of rope fall wraps: Other(s):
Type of lifting Gear(s): Chain Sling, Lifting Beam, SWL:
No. Of Legs: Shackle, SWL:
Each Leg Capacity: Chain Blocks, SWL:
SWL: Hook with latch, SWL:
Webbing Sling, SWL: Eye Bolt/Nut, SWL:
Wire Rope, SWL: Other(s):

4. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)

Planning Checks Yes-No-NA Operational Checks Yes-No-NA
Risk Assessment/ Method Statement Crane Outriggers Fully Extended And
Developed, Approved And Communicated? Grillage/ Spreading Pads In Place
Employees Are Consulted And Trained? All Wheels Are Off The Ground.
ASAK/HSE/1185/PTW/LO/00 REV. 00 Dated 25th July. 2024 Page 1 of 2
 ASAK HSE DEPARTMENT
LIFTING OPERATION : WORK PERMIT
SWL And Radius Indicators In Working
Provision Of Vigilance Supervision?
Order With Visual And Audible Warning
Has The Crane Valid Certification Wind Indicator Is Fitted & In Working Order
Load(S) Slung Correctly By A Competent
Has The Lifting Gears Valid Certification
Rigger
Riggers/Slinger Competent And Certified Tag-Line(S) Are Connected With The Load
Correct Crane Selected For The Load(S) And Suspended Load Slewing Path Is Cleared
Radius From People And Barricaded
Destination Of Load(S) Is Cleared And
Ground Suitable, Even, Firm And Prepared
Prepared Sufficiently
Load Rating Chart For The Crane Is
Safe Means Of Access/Egress Provided?
Available
Communication Aid Available (Radio
Crane Is Set Up Away From Excavation (Dx1.5)
Device)
Crane Swing Radius Area Is Free From Overhead
Click here to enter text.
Cable/ Structure Or Other Cranes
Proper Barricade And Signage Are Posted? Click here to enter text.

5. Acknowledgement & Authorization: (To be filled by initiator/originator)

Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives,
and I consider them competent to do it safely.
Initiator/Originator name Title
Signature Date /Time
(To be filled by Evaluator)
Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (safety staff) name: Title
Signature: Date /Time

Extra Measures (if any)

Authorization: (To be filled by Approving Authority PM/PE)
Approving Authority name: Title

Signature: Date /Time

6. Completion/ Cancelation: (To be filled by initiator/ receiver )

Work completed housekeeping Done Protected the area Other
Acknowledge that I have completed the work detailed in this permit and have restored the location to a safe and
orderly condition.
Receiver name: Title
Signature: Date /Time
7. 6.a Completion/ Cancelation: (To be filled by issuer (safety officer)
Work completed Job on hold Permit Cancelled Other
Reason if any: Time:
Evaluator: Title
Signature: Date /Time

ASAK/HSE/1185/PTW/LO/00 REV. 00 Dated 25th July. 2024 Page 2 of 2