Title Page
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Project title
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Location of work
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Date
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Description of work
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Permit applicant (Lifting Supervisor)
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To attach photo of evidence as much as possible
Lifting details
A) Details of lifting crew
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Lifting Supervisor
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Lifting Supervisor
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Crane Operator
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Crane Operator
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Rigger
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Rigger
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Signalman
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Signalman
B) Details of lifting equipment
Lifting machines
LM 1
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Type of equipment
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LM No.
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Date of expiry
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Maximum SWL
LM 2
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Type of equipment
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LM No.
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Date of expiry
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Maximum SWL
Lifting gears
LG 1
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Type of equipment
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LG No.
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Date of expiry
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SWL
LG 2
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Type of equipment
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LG No.
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Date of expiry
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SWL
LG 3
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Type of equipment
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LG No.
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Date of expiry
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SWL
LG 4
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Type of equipment
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LG No.
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Date of expiry
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SWL
LG 5
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Type of equipment
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LG No.
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Date of expiry
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SWL
LG 6
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Type of equipment
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LG No.
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Date of expiry
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SWL
C) Details of load / material
Load 1
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Description of load
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Dimension
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Weight of load
Load 2
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Description of load
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Dimension
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Weight of load
Load 3
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Description of load
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Dimension
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Weight of load
Load 4
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Description of load
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Dimension
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Weight of load
Load 5
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Description of load
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Dimension
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Weight of load
Load 6
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Description of load
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Dimension
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Weight of load
Load 7
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Description of load
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Dimension
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Weight of load
Load 8
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Description of load
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Dimension
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Weight of load
Lifting calculations base on the maximum load
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Maximum load
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Maximum working radius
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Corresponding SWL
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Weight of lifting gears
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Factor of safety: safe working load / (maximum weight of load + weight of lifting gears) =
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Crane capabilities: (maximum weight of load + weight of lifting gears) / safe working load X 100= %
Endorsement of PTW
Section A- Permit applicant
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I hereby submit this form for clearance prior to lifting activity. I fully understand the nature of work & confirm the lifting activity is WSH compliance
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Name
Section B- SHE Personnel
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I have reviewed the permit and SHE requirements for the work and instructed all personnel to eliminate or critically reduce the risks and impacts. Work shall be stopped if there is a change in work conditions.
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Name
Section C- Operation manager / Field Manager / Project Manager
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I am satisfied that all reasonably practicable measures are / will be implemented and enforced, and the working personnel are informed of the Safety, Health, Environment hazards / impacts. Work shall be stopped if there is a change in work conditions.
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Name
Section D- Closing of permit by Permit applicant
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Status of closing permit
- Work completed
- Housekeeping had been carried out
- Work area is safe for other personnel
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Permit applicant
SHE requirement prior to lifting activity
Physical & environmental considerations
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To take photo as much as possible
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Briefed lifting crew of the activity
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Lifting crew to check LM / LG before use
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Are the outriggers evenly extended?
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Is the ground made safe (e.g., placing steel plate)?
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Are there any overhead obstacles such as power lines?
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Are there nearby buildings or structure, equipment or stacked materials that may obstruct lifting operation from being carried out safely?
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Has the zone of operation been barricaded (with warning signs and barriers) to prevent unauthorised access?
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Is the lighting condition adequate?
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Means of communications
- Radio
- Verbal
- Hand signals
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No strong wind or thunderstorm?
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Provision of tagline?
Inspected by
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Lifting Supervisor
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Overall safe to work
Verified by
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Safety Personnel
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Evaluation
