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1、PermittoWork工作许可证PermittoWork/工作许可证Area/Location工作区域/详细位置Namelistoftheinvolvedworkers/工作人员名单标名特殊工种ContractorsOperationAuthorityIwillensuretheworkforceundermycontrolread,andcomplywithriskassessment(JSA),RequirementbythisPermittoWorkandsafetymethodstatement.Iwillguaranteethefieldmonitoringandsupervisi
2、onandensurethesafeexecutionofthiswork.IwillnotifytheSiteAuthorityoncompletionorinterruptionofthiswork.我保证我的下属阅读,理解和执行风险评估,许可证要求及安全施工方案.我将保证监护管理以确保安全施行,并且在这个工作完成或终止时通知项目区域负责人.现场十分指令:IhavereviewedthisworkpermitandattacheddoctoWork).我已经审核过该许可证及附属文件并与,umentandalsohavephysicallyinspectedthe相关所有方一起检查过现场.我
3、批准工workareawithallparties.I乍能够按许可证要求开场作herebyauthorizetocommeneetheworkasthisPTW(Permitk.GCPerson总包施工主管Date日期GCPerson总包安全主管Date日期CAFPEDept长安福特设备工程部主管工程师技安工程师经理CAFSafetyDept.长安福特安全部Date日期Applicant申请者Date日期Distribution:OriginalDisplayedatWorkSite,aftertheworkreturntoCAFsafetyDep.原件由申请人置于作业现场;工作完成后,工作许
4、可证关闭后由申请人交CAF安全部处存档AfterapprovedbyCAFsafetyDep,ApplicantwriteonthedisplayboardofCAFsafetyDep.工作许可证经CAF安全部批准后,由申请人在工作许可证一览表上登记;SafetyWorkPermitContractor施工单位Applicant申请者ApplicationDate申请日期Task任务描绘:UseofHeavyEquipment/使用重型设备DoubleLanyards双系索Dailsafettalaldsettle班前会能否已EquTpmen3olal3yinspeete机具具sorrcDes
5、idexcavatioa坑边堆Workplaceinspection/recordateachshiftstarting班前检查并记录WorkPlaceBarricadeandIsolation现场围护或隔离WorkplaceStandbyPerson/Watchman现场监护人/看护人ProvideSuitableAccessandEgress提供适宜的出入通道PostingWarningSigns竖警示/警告牌,标志FireProtection(Extinguisher/Sands)防火措施(灭火器/沙)EnergyIsolation(LockOutandTagOut)能量隔离(挂锁/标签
6、)ReinforcingFieldLighting改善现场照明ReinforcingVentilationCondition加强现场通风(强迫通风)ElectricalSystemtobecheckedandcertified电气系统的检查及鉴定GasTestRequired气体测试i-all/rallingProtectionNets,Canopy,Lifeline,Scanolds坠落物/坠落防护安全网,蓬,平台,生命绳等Purging,Flushing,Depressurizing,吹扫,冲洗,卸压MaterialSafetyDateSheet(MSDS)材料安全数据单Methodsta
7、tementavailable,能否有作业方案YNN/A已确认地下无其它设施,确认人签字:总包单位:土建电仪工艺管线现场其它条件备注:ElectricalIsolationsCompleted电气完全隔离是YES否NO不需要NALocations:位置SpecialInstructions:十分指令MechanicalIsolationsCompleted机械完全隔离是YES否NO不需要NALocations位置ProcessLineIsolationsCompleted工艺管线完全隔离是YES否NO不需要NALocations位置RiskAssessmentAttached附风险评估YESN
8、OMethodStatementAttached附施工方法讲明YESNODrawingsAttached附图纸YESNOVerifiedby(Signature)负责人签名:ApplicantAcknowledgementJobconditions(equipment/area)areinsafeconditionfortheproposedworkspecifiedinthispermit.此工作许可证规定的工作条件(设备/区域)处于安全状况.IwillbethePTWRecipientandastheresponsibleperson丨willensureallworkissupervis
9、edbymyselfatalltimes.我作为本工作许可证的责任人/接受人,我将对本工作负责并确保总是监护本工作进行ApplicantSignature申请人签字:日期:联络电话:Watchman监护人:Approvalbycontractor施工单位批准GC/ContractorConst.总包/分包施工主管Date/Time:GC/ContractorSafety总包/分包安全主管Date/Time:Typeofwork/工作类别施工单位勾选DrawingNo.图纸号Lifting/起重吊装Electric/PowerWork电器/电源作业FloorOpening/楼板开孔作业Radia
10、tion/探伤作业ConfinedSpaceEntry/受限空间作业PressureTest试压Excavation/动土开挖WorkingatHeight/高空作业Workimpactaccess占道施工Others/其他Night/OTShift夜班/加班口HotWork/动火作业Fence/barricadesremove/围栏/防护栏杆移除Corrosivematerials腐蚀物EarthCollapsed塌陷Electricity带电TieInWork管线连接ScaffoldingErection/脚手架搭建/拆除yingparticles/sparksNakedflamesora
11、rcs明火或电弧Radioactivematerials放射性物质High/lowtemperature高/彳氐温Other其它:iquidorgas-FallingObjects物体下落Toxicmateriar有毒物Confinedspace受限空间Poorlighting照明不好Adverseweather不利天气ammableExplosive易爆InerfGas;惰性气体RunningMachinery运转设备Traffic交通Noise噪音LiftingOperation起吊作业arRespiratoryMask呼吸面罩ProtectiveSuit防护服assesProtectionGloves防护手套FaceShield防护面罩earingProtectionSafetyHarness安全带OtherPPE(pleasedescribe)其它防护用品(请描绘):IhaveconfirmedthattheElectrical/MechanicalIsolationandValveCheckshavebeendoneaspertheneedoftheparticularoperationspecifiedinthisWorkPermit.我确认已经根据本许可证限定的操作安全要求进行了电气、机械隔离,阀门检查等措施。Date/Time日期/时间:
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