JKT09 - Hot Work - Permit to Work
KOESTRIONO KOESTRIONO - PT. Atlas 2025-02-17
ID 121411 Created by Jaya Konstruksi 11:13:52
JKT - 09
Select Department CSA
Trade Contractor Name / Nama Kontraktor: PT. Atlas Jaya Konstruksi
Name: PT. Atlas Jaya Konstruksi
Address Line 1: Jl Dr. Makaliwe
Address Line 2: Grogol
Address Line 3 no 28
City
Postcode
SECTION 1 – APPLICATION FOR PERMIT–TO–WORK / Pengajuan untuk Izin Kerja
(To be filled by supervisor of a person who is to conduct hot work, submitted to Appointed Safety Assessor
and addressed to Appointed PM/Competent Person)
(Diisi oleh atasan seseorang yang akan melakukan pekerjaan panas, diserahkan kepada Assessor
Keselamatan yang Ditunjuk dan ditujukan kepada PM/Orang yang Kompeten yang Ditunjuk)
DataTouch Area: JKT 09 Main Work (RC Work)
Location of Work / Lokasi Kerja: Zona 7&8
Validity of the Permit / Validasi Izin Kerja
Date / Time Date / Time
Start / Dari 2025-02-16 End / Sampai 2025-02-23 Duration 8 Days
Hari/ Tanggal: Hari/ Tanggal:
1. Fabrikasi bekisting
Description of Works / Machineries used / 2. Pengelasan
Deskripsi Pekerjaan/Mesin yang digunakan:
Mesin : Travo las, Circular saw, Gerinda, Palu
No. Of Workers / Jumlah Pekerja: 6
Name of Fire Watcher / Nama Fire Watcher:
Name Added Photograph
SUHENDI SUHENDI 2025-02-17 11:12:10
First Name: SUHENDI
Surname: SUHENDI
City: PURWAKARTA
HASANUDDIN HASANUDDIN 2025-02-17 11:12:17
1
First Name: HASANUDDIN
Surname: HASANUDDIN
City: JEPARA
SECTION 2 – SAFETY CHECKLIST
(To be filled by supervisor of a person who is to conduct hot work) / (Diisi oleh atasan seseorang yang akan
melakukan pekerjaan panas)
Description / Deskripsi Yes / Ya No / Tidak N/A Remarks / Keterangan
1. Are Risk Assessment
and Safe Work Procedure
being conducted for
respective work activity? / ✓
Apakah Penilaian Risiko
dan Prosedur Kerja Aman
dilakukan untuk masing-
masing aktivitas kerja?
2. Are there any
flammable/combustible
materials/gases/liquid
present near work area? /
Apakah terdapat ✓
bahan/gas/cairan yang
mudah terbakar/mudah
terbakar di dekat area
kerja?
3. Has the check on gas
hose for leak by using
soap solution? / Apakah
selang gas sudah diperiksa ✓
kebocorannya dengan
menggunakan larutan
sabun?
4. Are the gas cylinder
standing on upright
position and secured? / ✓
Apakah tabung gas
berdiritegak dan aman?
5. Is there a fire
extinguisher provided? / ✓
Apakah tersedia alat
pemadam kebakaran?
6. Are all electrical machine
properly
earthed/grounded? / ✓
Apakahsemua mesin listrik
dibumikan/dibumikan
dengan benar?
7. Is there a flash back
arrestor in place for the
Oxy acetylene set? / ✓
Apakah terdapat flash back
arrestor yang terpasang
pada Oxy acetylene set?
8. Is gas test required? If
yes, record the gas test
using gas testing records /
Apakah uji gas diperlukan? ✓
Jika ya, catat pengujian
gas menggunakan catatan
pengujian gas
2
9. Any incompatible
activity near to the
intended work location? / ✓
Adakah aktivitas yang tidak
sesuai di dekat lokasi kerja
yang dituju?
10. Is adequate lighting
provided for the access &
work area? / Apakah ✓
penerangan yang memadai
disediakan untuk akses &
area kerja?
11. Is hot work area
barricaded & warning sign
displayed? / Apakah area ✓
kerja panas dibarikade dan
tanda peringatan
ditampilkan?
12. Is blower / exhaust fan
installed and has it been
commissioned? / Apakah ✓
blower/exhaust fan sudah
terpasang dan sudah
dioperasikan?
SECTION 3 – DECLARATION & EVALUATION OF APPLICATION / DEKLARASI &
EVALUASI APLIKASI
I have checked the abovementioned area and I am satisfied that it is safe for hot
works. I understand all safety precautions to be taken under current legislation
and all persons involved are informed of the hazards of Hot Work during Pre-
task Analysis. / Saya telah memeriksa area tersebut di atas dan saya puas karena ✓
area tersebut aman untuk pekerjaan panas. Saya memahami semua tindakan
pencegahan keselamatan harus dilakukan berdasarkan undang-undang yang
berlaku saat ini dan semua orang yang terlibat diberi informasi tentang bahaya
Pekerjaan Panas selama Analisis Pra-tugas.
Applicant Name and Signature / Nama dan Tanda Signature
Tangan Pemohon:
Rizqi Aldi Pratama
Document Images
3
4
JKT09 - Hot Work - Permit to Work - Supervisor Approval
Christover Aginta Sebayang - PT. Jaya 2025-02-17
ID 121468 Created by Obayashi 14:00:12
Declaration:
I verified that the above-mentioned area has been checked and in circumstances ✓
noted, I am satisfied that it is safe to carry out work at this area.
Comments:
Name and Signature of Obayashi Supervisor: Signature
Christover
5
JKT09 - Hot Work - Permit to Work - Site Manager Sign off
2025-02-17
ID 121519 Created by Zaenal Mahfudzi - PT. Jaya Obayashi 16:27:39
Declaration:
I verified that the above-mentioned area has been checked and in circumstances ✓
noted, I am satisfied that it is safe to carry out work at this area.
Comments:
Name and Signature of Obayashi Site Manager: Signature
Zaenal Mahfudzi
6
JKT09 - Hot Work - Permit to Work - Project Manager / Project Director Sign off
2025-02-17
ID 121537 Created by Hiroyuki Kunita - PT. Jaya Obayashi 20:24:39
Declaration:
I verified that the above-mentioned area has been checked and in circumstances ✓
noted, I am satisfied that it is safe to carry out work at this area.
Comments:
Name and Signature of Obayashi Project Signature
Manager:
Kunita
7
Queue Move History
Document Reason Date Moved Moved By Moved From Moved To
MoveDocument
ScheduleQueue
sBackgroundJo
b: Permit
requires Daily Hot Work
JKT09 - Hot Hot Work
Endorsement. 2025-02-18 Permit - Daily
Work - Permit to - Permit - Issued
Please 04:00:40 Endorsement
Work (121411) and Live
complete the Required
document for
Permit to be
activated for
today.
Hot Work
Permit -
JKT09 - Hot . Submitted Hot Work
2025-02-17 Hiroyuki Kunita Pending Project
Work - Permit to from mobile Permit - Issued
20:24:41 (User Id: 1590) Manager /
Work (121411) app. and Live
Project Director
Sign Off
Hot Work
Hot Work Permit -
JKT09 - Hot . Submitted Zaenal Permit -
2025-02-17 Pending Project
Work - Permit to from mobile Mahfudzi (User Pending Site
16:27:41 Manager /
Work (121411) app. Id: 15473) Manager Sign Project Director
Off Sign Off
Hot Work Hot Work
Christover Permit
JKT09 - Hot . Submitted Permit -
2025-02-17 Aginta Submitted -
Work - Permit to from mobile Pending Site
14:00:14 Sebayang (User Pending
Work (121411) app. Manager Sign
Id: 12345) Supervisor Off
Approval
Hot Work
Document Permit
JKT09 - Hot KOESTRIONO
Submitted. 2025-02-17 Submitted -
Work - Permit to KOESTRIONO -
Submitted from 11:13:57 Pending
Work (121411) (User Id: 12741)
mobile app. Supervisor
Approval
