Doc.

No : 2015-028-A
Technical Affairs Department/Safety & Security Department/Fire Department Rev. No : 0
17-Feb-16
Eff. Date :
KSAU-HS WORK Permit Official Form Page No : 13
Work Permit Instruction:

1. Contractor fill the section "Work/Project General Informations" in this Work Permit and send it to TA Departement for his necessary action.
2. The TA Departement completed the section "Request & Completion Approval" in this Work Permit and sign.
3. The TA Departement send the Work Permit to concerned departments for their necessary actions and approval.
4. The concerned departments (Safety and Fire) verify the Safety/Fire requirements, complete the permits required by this task and approve the Work Permit if contractor complying with the
requirements.
5. Concerned departments should be at site on the time of work mentioned in the Work Permit to verify the Safety/Fire requirements and give the approval.
6. The contractor should call 88 (Fire Department) and 111 (Safety Department) 60 minutes before starting the work.
7. No work shall be done without site approval from Safety Department and Fire Department.
8. Technical Affairs only confirms the existence of the problem/issue and the estimated time for reparation.
Work/Project General Informations TA Use Only (Request & Completion Approval)
Issue Date: W.P. No.: This permit addressed to the following concerned departments for approval:

Date of work to start: 24 May 2017 Time of work to start: 08:00am Safety Department. Fire Department. Security Department.

Date of work completion: 05 JUNE 2017 Time of work to completion: 04:00pm Other:

Exact Location: ROAD WAY NEAR MAIN GATE NO 2 Work permits requested by this task and addressed to concerned departments for approval:

Work Supervisor Contractor Supervisor General Work Permit. LPG Work Permit.
Name: ENG. MOHAMMAD TOEMA ENG.ABDULRAHMMAN ISM Hot Work Permit. Construction/Excavation Work Permit.
Signature: Electrical Work Permit. Work At High Permit.
Mobile #: 0582582777 0593324666 Confined Space Entry Permit. Work on Safety Systems Permit.
Email: mech.ngr@jash.com.sa a.rahman@jash.com.sa Pipe Medical Gas Work Permit. Other:

DESCRIPTION OF WORK TO BE DONE: RECTIFICATION IN DOMESTIC WATER Approval of requestor of the work:

SUPPLY LINE. TA Signature: Date:

TA Supervisor Signature: Date:

Approval of Concerned Departments
The contractor will call 88 (Fire Department) and 111 (Safety Department) 60 minutes before starting the work in order to confirm your attendance
Safety Department Signature: Date: Fire Department Signature: Date:

Permit Holder Signature: Date: Other Department Signature: Date:

 KSAU-HS WORK PERMIT Doc. No : 2015-028-A
Rev. No : 0
Technical Affairs Department/Safety & Security Department/Fire Department 17-Feb-16
Eff. Date :
GENERAL WORK Official Form Page No : 13

"This GENERAL Work Permit is required only for Low Risk Activities inside KSAU-HS Campus."

ENSURE PRECAUTIONS ARE IN PLACE!

MAKE SURE AREA OF WORK WAS ISOLATED, SPRINKLERS ARE IN SERVICE AND FIRE EXTINGUISHERS ARE READILY AVAILABLE !
Note : The Required Precautions are not optional. They are required for safe Construction/Excavation work. Please explain all No responses in the back.
Tools/Equipment to be used: Means used to restrict the access of unauthorized personnel from the work area:
Signs/Tags. Barricades. Isolation. Other:
PPE Required:
Hearing Protection. Face Shield.

Person(s) doing the work has/have been attended to Safety Orientation Course in KSAU-HS ? Gloves. Safety glasses.
Job Safety Analysis (JSA) has been completed for this work ? High visibility Jacket. Hard Hat.
Used tools and equipment are in good condition ? Respirator Mask. Safety Shoes.
Does the work involve high noise ? Special Tools and Equipment Required Needed:
Does the work involve using hazardous material ? (If "Yes" attach the MSDS of hazardous materials used)

Does the work involve blocking egress routes ? (If "Yes" attach location of new egress routes and emergency exits)
Does the work involve cranes/overhead load movement ? (If "Yes" attach last Motor Vehicle Periodic Inspection)

Underground/under walls utilities (Piping, Electric, etc.) located, verified and marked ? Fire and Evacuation:
Does the work affect safety systems ? (If "Yes" Implement Interim Life Safety Measures (ILSM)) Fire extinguishers required ? Fire procedure understood ?
Does the project involve disabling services(power/water/sewage) ? Fire blanket required ? Location of nearest fire alarm known ?
General Rules: Clean Agent System/Sprinklers in service ? Escape routes maintained and known
The work permit can be cancelled by any employee in case the laid-down precautions and safety by personnel ?
measures are not being followed. Permit Renewal (Only if Safety and Fire requirements are always implemented)
Contractor should not obstruct traffic inside and outside KSAU-HS Campus.
Put safety signs and warning signs at the entrances of area of work. From: To: Signature:
Contractor must isolate work area from the rest of the building.
Contractor must ensure no dust or smoke seep to outside area of work. From: To: Signature:
All debris must be removed from within buildings in closed containers.
All debris must be kept in contractor's containers. From: To: Signature:
Safety Department Authority
Valid From Valid To Time Start Time End Date
Signature
 Work Permit Clearance
Gas has been re-connected to the work area after completion of work and the LPG system is in good operation ?
Valve of riser related to this work has been opened after completion of work and locks removed ?
Valves and Gages in work area, in riser and in main tank has been checked after completion of work and are in good operation ?
There is no gas leak in atmosphere of work area after completion of work ? (Atmosphere must checked and tested with gas detector).
Work area was kept ventilated after completion of work ?
Fire Watch completed final inspection and return to designated area after 6 hours from completion of work ?
Safety Inspector have no comments related to safety after completion of work ?
Fire watch have no comments related to fire/safety after completion of work ?

Details any incomplete work here:

I assure that the site has been left in a safe condition and clean with any necessary locks removed, the system tested and is in good condition and I'm aware
about the incomplete work noted above.
Permit Holder Signature

Fire Department Authority Safety Department Authority

TA Engineer Signature
Signature Signature
The Permit-Authorizing Individual must:
a) Verify precautions listed at the back (or do not proceed with the work).
b) Complete this page and give original copy to Permit Holder to put in Work Area.
c) Give copy of this page to the Fire Watch, Safety Inspector, TA Engineer and TA Safety Engineer.
The Permit Holder must: Indicate time started and post the permit at work location. After LPG work, inform Permit Authority, TA Engineer, Fire Watch, Safety Inspector and return the original copy of this permit to Permit-Authority.
Fire Watch must: Prior to leaving area, do final inspection, leave permit posted and notify Permit Holder.
Clearing the Permit: Each permit is for a specific location, time frame, and task.
Permit Holder is responsible for leaving the work area clean and tidy, and removing locks and personal danger tags used for the equipment isolations.
Once work has been complete or Work Permit expires, permit must be closed out and reports to the Permit Authority.
If the job is incomplete, details of work to be carried over to next day are to be noted in space provided above of original by Permit Holder.
Any incidents, unexpected occurrences or deviations from regular work practices will be noted and discussed with the workers doing this work and their supervisors.
The Work Permit must be retained as record for 6 months minimum.
In case of emergency call: TA-U&M Hotline: 92211 / Safety Department: 111 / Fire Department: 88
 KSAU-HS WORK PERMIT Doc. No : 2015-028-A
Rev. No : 0
Technical Affairs Department/Safety & Security Department/Fire Department 17-Feb-16
Eff. Date :
CONSTRUCTION/EXCAVATION WORK Official Form Page No : 13

"This CONSTRUCTION/EXCAVATION Work Permit is required for any operation involving working in construction inside KSAU-HS Campus."

ENSURE PRECAUTIONS ARE IN PLACE!

MAKE SURE AREA OF WORK WAS ISOLATED AND SAFETY REQUIREMENT ARE READILY APPLIED!
Note : The Required Precautions are not optional. They are required for safe Construction/Excavation work. Please explain all No responses in the back.

Project# Project Name

Person(s) doing the work has/have been attended to Safety Orientation Course in KSAU-HS ? Means used to restrict the access of unauthorized personnel from the work area :
Person(s) doing work knowing and understanding the KSAU-HS Construction/Excavation protocol and Signs/Tags. Barricades. Isolation. Other:
procedure ? PPE Required:
Job Safety Analysis (JSA) has been completed for this work ? Hearing Protection. Face Shield.
Interim Life Safety Measures (ILSM) required ? (If "Not" attach the ILSM Assessment Form) Gloves. Safety glasses.
Used tools and equipment are in good condition ? High visibility Jacket. Hard Hat.
Does the project involve high noise ? Respirator Mask. Safety Shoes.
Does the project involve using hazardous material ? (If "Yes" attach the MSDS of hazardous materials used) Other:
Does the project involve blocking egress routes ? (If "Yes" attach location of new egress routes and emergency exits) Fire and Evacuation:
Does the project involve cranes/overhead load movement ? (If "Yes" attach last Motor Vehicle Periodic Inspection) Fire extinguishers required ? Fire procedure understood ?
Underground utilities (Piping, Electric, etc.) located, verified and marked ? Fire blanket required ? Location of nearest fire alarm known ?
Evidence of caving, shrinkage cracks or sloughing of soils and/or walls observed ? Clean Agent System/Sprinklers in service ? Escape routes maintained and known
Does the project involve disabling services(power/water/sewage) ? by personnel ?
Important Precautions and Requirements: Permit Renewal (Only if Safety and Fire requirements are always implemented)
Contractor Must assign safety officer and fireman in area.
Contractor Must provide "Fire Fighting equipment" and "First Aid Box" around and inside the work area. From: To: Signature:
Contractor must isolate work area from the rest of the building.
Contractor must ensure no dust or smoke seep to outside area of work. From: To: Signature:
All debris must be removed from within buildings in closed containers.
All debris must be kept in contractor's containers. From: To: Signature:
Contractor must adhere to project's scope of work.
Contractor should not obstruct traffic inside and outside KSAU-HS Campus. From: To: Signature:
Put safety signs and warning signs at all entrances to the site.
Safety Department Authority
Valid From Valid To Time Start Time End Date
Signature