PermittoWork工作许可证

Permit to Work /工作许可证

Area/Location

工作区域/具体位置

Name list of the involved workers/工作人员名单（标名特殊工种）

Con tractor ' s Operati on 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 en sure the safe executi on of

this work. I will no tify the Site Authority on completi on or in terrupti on 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.

现场特别指令：

I have reviewed this work permit and attached doc to

Work).我已经审核过该许可证及附属文件并与,

,ument and also have physically in spected the 相

关所有方一起检查过现场.我批准工

work area with all parties. I

乍可以按许可证要求开始作hereby authorize to comme nee the work as this PTW (Permit k .

GC Pers on

总包施工主管Date

日期

GC Pers on

总包安全主管Date

日期

CAF PE Dept

长安福特设备工程部

主管工程师技安工程师经理CAF Safety Dept.

长安福特安

全部Date

日期

Applicant申请者Date日期

Distributi on:

Original —Displayed at Work Site，after the work return to CAF safety Dep. 原件由申请人置于作业现场；工作完成后，工作许可证关闭后由申请人交CAF安全部处存档

After approved by CAF safety Dep，Applicant write on the display board of CAF safety Dep . 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；

Safety Work Permit

Con tractor 施工单位Applica nt 申请者

Applicatio n Date 申请日期

Task任务描述:

Use of Heavy Equipme nt/使用重型设备

Double Lany ards 双系索

Dail^safet^tal^al^^d^settle^班前会是否已EquTpmen^^3ol^al^^3yinspeete^机具具^^^sor^^rc^Desid^excavatio^a^^坑边堆

Workplace inspection/record at each shift starting 班前检查并记录Work Place Barricade and Isolation 现场围护或隔离Workplace Standby Person/Watchman现场监护人/看护人

Provide Suitable Access and Egress 提供合适的出入通道Posting Warning Sig ns竖警示/警告牌，标志Fire Protection (Extinguisher/Sands)防火措施(灭火器/沙)

Energy Isolation (Lock Out and Tag Out)能量隔离(挂锁/标签) Reinforcing Field Lighting 改善现场照明Reinforcing Ventilation Condition 加强现场通风(强制通风)

Electrical System to be checked and certified 电气系统的检查及鉴定Gas Test Required 气体测试~i-all/ralling Protection （Nets，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Material Safety Date Sheet (MSDS)材料安全数据单Method stateme nt available，是否有作业方案Y N N/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：

Electrical Isolati ons Completed 电气完全隔离是YES 否NO 不需要NA Locations:位置Special Instructions:特别指令

Mecha nical Isolati ons Completed 机械完全隔离是YES 否NO 不需要NA Locations 位置

Process Li ne Isolati ons Completed 工艺管线完全隔离是YES 否NO 不需要NA Locations 位置

Risk Assessme nt Attached

附风险评估

YES NO

Method Stateme nt Attached

附施工方法说明

YES NO

Drawings Attached 附图纸

YES NO

Verified by(Signature)

负责人签名：

Applica nt Ack no wledgeme nt

Job con diti ons (equipme nt/area) are in safe con diti on 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 Recipie nt and as the resp on sible pers on 丨will en sure 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: 联系电话:

Watch man监护人:

Approval by con tractor 施工单位批准

GC / Co ntractor Co nst.

总包/分包施工主管

Date/Ti me:

GC / Con tractor Safety 总包/分

包安全主管

Date/Time:

Type of work/工作类别（施工单位勾选）Drawi ng No.图纸号

Lifting/起重吊装Electric/Power Work 电器/ 电源作业Floor Ope ning/楼板开孔作业

□□

Radiati on/探伤作业Confined Space En try/受限空间作业

Pressure Test试压

□□Excavati on/动土开挖Working at Height/ 高空作业Work impact access 占道施工

□□

Others/其他

Night/OT Shift 夜班/加班口

Hot Work/动火作业

Fence/ barricades remove

/围栏/防护栏杆移除

Corrosive materials 腐蚀物

Earth"Collapsed 塌陷

Electricity 带电

Tie In Work管线连接

Scaffoldi ng Erecti on/

脚手架搭建/拆除

ying particles / sparks

Naked flames or arcs 明火或电弧

Radioactive"materials"放射性物质

High / low temperature 高/彳氐温

Other其它:

iquid or gas -

Falling Objects 物体下落

Toxic"materiar 有毒物

Confined space 受限空间

Poor lighting照明不好

Adverse weather 不利天气

ammable

Explosive 易爆

In erfGas ;惰性气体

Running Machi nery 运转设备

Traffic 交通

Noise噪音Lifting Operation 起吊作业

ar

Respiratory Mask 呼吸面罩

Protective Suit 防护服

asses

Protection Gloves 防护手套

Face Shield防护面罩

eari ng Protection

Safety Har ness 安全带

Other PPE (please describe)其它防护用品(请描述)：

I have con firmed that the Electrical/Mecha ni cal Isolati on and Valve Checks have bee n 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。

Date/Time

日期/时间: