动火和受限空间作业票 - 图文

Applicant 申请者 Contractor 承包商 Emergency No.紧急联络方式 Emergency Assembly紧急集合点: : Hot Work & Confined Space Work Permit/ 动火及受限空间作业许可证 Application Date申请日期 Area/Location /Task工作区域 / 具体位置/任务描述: Type of work/工作类别 Hot Work/动火作业 Confined Space Entry/受限空间作业 Liquid or gas 液体或气体 Falling Objects 物 体下落 Toxic material 有毒 物 Confined space 受 限空间 Poor lighting 照 明不好 Adverse weather 不利天气 Applicants Quick Reference of Hazards/可能存在的危害因素 Work at Height 高处作业 Flammable 易燃物 Corrosive materials 腐蚀 物 Earth Collapsed塌陷 Electricity带电 Tie In Work管线连接 Noise噪音 Explosive 易爆 Inert Gas 惰性气体 Running Machinery 运转设备 Traffic 交通 Lifting Operation起吊作业 Flying particles / sparks 飞 尘/ 火花 Naked flames or arcs 明火或 电弧 Radioactive materials 放射性 物质 High / low temperature 高/低 温 Other 其它: 需要的个人防护用品 Applicants’ PPE to Be Used/Hard Hat 安全帽 Respiratory Mask呼吸面罩 Protective Suit 防护服 Safety Glasses 安全眼镜 Protection Gloves 防护手套 Face Shield 防护面罩 Hearing Protection 耳塞/耳罩 Safety Harness 安全带 Fire proof suit防火服 Double Lanyards 双系索 Other PPE (please describe)/其它防护用品（请描述）： he Work Site/现场需要采取的措施 Applicant’s Measures to Be Taken at TWorkplace inspection/record at each shift starting每次班前检查并记录 Provide Suitable Access and Egress 提供合适的出入通道 Energy Isolation (Lock Out and Tag Out) 能量隔离(挂锁/标签) Electrical System to be checked and certified 电气系统的检查及鉴定 Purging, Flushing, Depressurizing, 吹扫,冲洗,卸压 Work Place Barricade and Isolation 现场围护或隔离 Posting Warning Signs 竖警示/警告牌,标志 Reinforcing Field Lighting 改善现场照明 Gas Test Required 气体测试 Material Safety Date Sheet (MSDS) 材料安全数据单 Workplace Standby Person/Watchman 现场监护人/看护人 Fire Protection (Extinguisher/Sands) 防火措施(灭火器/沙) Reinforcing Ventilation Condition 加强现场通风(强制通风) Fall/Falling Protection (Nets, Canopy, Lifeline, Scaffolds)坠落物/坠落防护(安全网,蓬,平台,生命绳等) Personal Safety Brief: Emergency Response, Evacuation, Communication, Standby Rescue Equipment, Gas Monitoring, Conditions of Work, Safe Work Method, Responsible Person. 人员安全交底:应急/疏散/通讯/现场救护设备/气体监测/工作条件/安全工作方法/负责人 其它措施Others: Applicant’s Isolation Verification(Electrical/Mechanical)/隔离绝缘验证(电气/机械) Is necessary ? 是否需要：Y是 N否 Electrical Isolations Completed电气完全隔离 Mechanical Isolations Completed机械完全隔离 Process Line Isolations Completed工艺管线完全隔离 Special Instructions:特别指令 I have confirmed that the Electrical/Mechanical Isolation and Valve Checks have been done as per the need of the particular operation specified in this Work Permit. 我确认已经按照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。 Risk Assessment Attached 附风险评估 Method Statement Attached 附施工方案 Drawings Attached 附图纸 YES YES YES YES YES YES NO NO NO Locations:位置 Locations位置 Locations位置 Verified by(Signature) 负责人签 名: Date/Time 日期/ 时间: NO NO NO Applicant Acknowledgement Job conditions (equipment/area) are in safe condition for the proposed work specified in this permit. 此工作许可证规定的工作条件(设备/区域)处于安全状况. I will be the PTW Recipient and as the responsible person I will ensure all work is supervised by myself at all times. 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. Applicant Signature申请人签字: 日期Date： Contractor’s Operation Authority I will ensure the workforce under my control read, and comply with risk assessment (JSA), Requirement by this Permit to Work and safety method statement. I will guarantee the field monitoring and supervision and ensure the safe execution of this work. I will notify the Site Authority on completion or interruption of this work. 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.我将保证现场监护管理以确保安全实施, 并且在这个工作完成或终止时通知项目区域负责人. Approval批准 GC / Contractor Const. 总包/承包商施工主管 GC / Contractor Safety 总包/承包商安全主管 Date/Time: Date/Time: Applicant Party’s Gas Test Result/气体测试批准 Is necessary? 是否需要: Y是 N否 Test Item 测试项目 O2 (19.5-22)氧气含量 Flammable Gas/易燃易爆气体 (0-5%LEL) Toxic Gas/有毒气体 Others/其它 Time 时间 Reading 读数 Time 时间 Reading 读数 Time 时间 Signature: Reading 读数 Time 时间 Reading 读数 The initial gas test has been completed: 初次气体测试已经完成 测试人 Safety Work Permit hot work & confined space 现场特别指令： Authorization/批准 I have reviewed this work permit and attached document and also have physically inspected the work area with all parties. I hereby authorize to commence the work as this PTW (Permit to Work). 我已经审核过该许可证及附属文件并与相关所有方一起检查过现场. 我批准工作可以按许可证要求开始作业. 许可证有效期（同一个工作可每日延期，最长可延7个工作日，周一统一重新开作业票） Approved Duration for this permit is 许可证生效期 GC Person 总包施工主管 GC Person 总包安全主管 日期 Date 日期 Date Extension 延期 Contractor Const. 分包施工主管 Contractor Safety 分包安全主管 GC Person 总包施工主管 GC Person 总包安全主管 PCM const. Person 管理公司施工主管 PMC safety Person 管理公司安全主管 Contractor Construction 承包商施工主管 GC Construction 总包施工主管 PCM const. Person 管理公司施工主管 Date日期 Extension of Permit/许可证延期 Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Signature Cancellation of Permit/许可证关闭 Contractor safety 承包商安全主管 GC Safety 总包安全主管 PMC safety Person 管理公司安全主管 Date日期 Date日期 Date日期 Date日期 Date日期 Name list of the involved workers/操作人员名单 监护人： 起重司机： 起重工： 挖机司机： 升降机司机： 其他关健施工人员： Distribution: Original—Displayed at Work Site. 原 件由申请人置于作业现场；作业票关闭后由总包处存档 Safety Work Permit hot work & confined space