PERMIT APPLICATION
Survey Form
INSTITUTION : DINAS KESEHATAN
PERMIT : IJIN FASILITAS MEDICAL
No
Description REVIEW
1 Name ...
Permit Classification:
 Technical
 Non- Technical
7 Documents Required:
1. SURAT PERMOHONAN KE BUPATI
2. Cq. KEPALA DINA...
9 Detail Duration to apply:
2-6 HARI KERJA KEPALA DINAS MENGELUARKAN REKOMENDASI
TENTANG PERIJINAN TERKAIT KEPADA BUPATI
1...
An Example for Application Procedure and Permit Issuing (Please modify as needed)
Activity
Party
Company Counter
1. Submit...
viii. H
ix. I
x. J
xi.
c. Technical requirements:
i. K
ii. L
iii. M
iv. N
v. O
vi. P
vii. Q
viii.
d. Other requirement as ...
List of Permit:
No PERMIT/LICENSE DESCRIPTION PURPOSE
1 Prohibited Areas and Confined Area Prohibited to enter area of FPS...
No PERMIT/LICENSE DESCRIPTION PURPOSE
34 Construction Permit for Special Terminal Construction permit respectively for ons...
No PERMIT/LICENSE DESCRIPTION PURPOSE
65 Occupational health and safety (company
doctors, paramedic officials, and expatri...
Ijin fasilitas medical
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Ijin fasilitas medical

  1. 1. PERMIT APPLICATION Survey Form INSTITUTION : DINAS KESEHATAN PERMIT : IJIN FASILITAS MEDICAL No Description REVIEW 1 Name Of Section/Directorate Dr. Juliana CH Ratuanak (Kepala Dinas) Dr. Lucia F.R.A. Filnditi (Kepala Bidang YANKESMAS) Dr. B. Clara Sumanik (Kepala Bidang P2MPL) 2 Contact person Dr. Juliana CH Ratuanak Dr. Lucia F.R.A. Filnditi ( 081399069800 ) Dr. B. Clara Sumanik ( 085239191933 ) DANIEL ARYESAM (082238116612) 3 Permit/License Description IJIN PENDIRIAN/ MENGADAKAN FASILITAS MEDICAL 4 Purpose UNTUK MELAYANI PENGOBATAN ATAU TINDAKAN DARURAT BAGI KARYAWAN 5 References: Law/Decree/Regulation PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 028 /MENKES/PER 2011 TENTANG KLINIK 6 Other Authority/Institution Involved (if any) KEMENTRIAN KESEHATAN
  2. 2. Permit Classification:  Technical  Non- Technical 7 Documents Required: 1. SURAT PERMOHONAN KE BUPATI 2. Cq. KEPALA DINAS KESEHATAN 3 AKTE PENDIRIAN PERUSAHAAN 4. SURAT KETERANGAN DOMISILI PERUSAHAAN 5. SUSUNAN PENGURUS DAN COPY KTP 6.TANDA DAFTAR PERUSAHAAN (TDP) 7.NPWP PERUSAHAAN 8.MELAMPIRKAN BIODATA DOKTER/PERAWAT 9. MELAMPIRKAN DAFTAR PERALATAN/JUMLAH ALAT MEDIS YANG DIGUNAKAN 10. SIUP Other Documents:  Study report  Survey report  Inspection report  Design Report  Other (specify) 8 Detail Procedure: (Narrative and Flow Chart) 1. SURAT PERMOHONAN DIAJUKAN KEPADA KEPALA DINAS KESEHATAN 2. SURAT PERMOHONAN DIEVALUASI DAN DIKAJI OLEH TIM TEKNIS 3. SUVEY LOKASI KLINIK DAN PENGECEKAN ALAT MEDIS YANG DIGUNAKAN 4. DIKELUARKAN REKOMENDASI DARI KEPALA BADAN/ DINAS
  3. 3. 9 Detail Duration to apply: 2-6 HARI KERJA KEPALA DINAS MENGELUARKAN REKOMENDASI TENTANG PERIJINAN TERKAIT KEPADA BUPATI 10 Permits / License Validity: 11 Associated cost: (Operational Cost) BEBAS BIAYA (GRATIS) 12 Note: CATATAN DARI KESEHATAN : UNTUK TAHUN 2013 PROSES PERIJINAN MEDIS MASIH GRATIS, TETAPI NANTINYA DITAHUN 2014 AKAN DIADAKAN KANTOR PELAYANAN TERPADU SATU ATAP YANG AKAN MENGATUR SEMUA BIAYA/TARIF.
  4. 4. An Example for Application Procedure and Permit Issuing (Please modify as needed) Activity Party Company Counter 1. Submitting Application 2. Application Evaluation 3. Approval Procedures 1. Company submit the application includes: a. Request letter b. Administration requirements: i. A ii. B iii. C iv. D v. E vi. F vii. G Apply Verification Pass? Disposition Disposition Pass? Pass? Pass? ???? Get Permit Yes Yes YesYes No No No No Duration Duration Duration Duration
  5. 5. viii. H ix. I x. J xi. c. Technical requirements: i. K ii. L iii. M iv. N v. O vi. P vii. Q viii. d. Other requirement as if needed 2. The application then will be verified by counter officer 3. Passed to ___________________________________ 4. Passed to ___________________________________ 5. R 6. S 7. T 8. U 9. V 10. W Note. a. All activities take about _______ working days b. If some requirements fail in evaluation, company request to apply again (from step 1).
  6. 6. List of Permit: No PERMIT/LICENSE DESCRIPTION PURPOSE 1 Prohibited Areas and Confined Area Prohibited to enter area of FPSO 2 Permits for entering Oil and gas Area Permit for Vessel entering area of Oil and Gas 3 Pressure Vessel Certification Equipment Safety Worthiness Certificate 4 Pedestal Crane Certification Equipment Safety Worthiness Certificate 5 Rotating Equipment Equipment Safety Worthiness Certificate 6 Electrical Equipment Certification Equipment Safety Worthiness Certificate 7 Flowline (including Flexible pipeline) Equipment Safety Worthiness Certificate 8 LNG Tank Equipment Safety Worthiness Certificate 9 LNG Installation/Plant Installation Operational Safety Worthiness 10 Pressure Safety Valves Final Popping Test Permit to ensure Pressurize Equipment are Protected per Design 11 Welders Performance License for welder performance 12 Welding Procedures Qualification Approval for Welding Procedures 13 Appointing Head of Safety of Mine (KepalaInspeksi) Acting as Directorate Technique MIGAS for case of emergency and all operational technical safety aspects of Plant. 14 Appointing Officer for seal & unsealed Pressure Safety Valve representing Directorate Technique of MIGAS Acting as Directorate Technique MIGAS to seal and unsealed of All Pressure Safety Valves in case of urgency of the Plant. 15 Centralized Storage use of Hazardous Waste (B3) Permits for meeting regulations requirements 16 Desalination Discharge Permit Permits for meeting regulations requirements 17 Hydrotest Water Discharge Permit Permits for meeting regulations requirements 18 Water Discharge Permit During Operation Permits for meeting regulations requirements 19 Permanent Hazardous Storage for Operation Permits for meeting regulations requirements - Dumping Permit - Landfill Permit 20 Emission from Non Point (Stationary) Source Permit Permits for meeting regulations requirements 21 Noise Level Permit Permits for meeting regulations requirements 22 Odor Level Permit Permits for meeting regulations requirements 23 Vibration Level Permit Permits for meeting regulations requirements 24 Incinerators Permits (Operation Permit) Permits for meeting regulations requirements 25 Forestry Release Permit Permits for meeting regulations requirements 26 Helideck Construction Permit Permit for Construction of Helideck 27 Helipad Construction Permit Permit for Construction of Helipad 28 Operational/landing Permit for Helicopter Permit for Operational of Helicopter 29 Helideck Operation Permit Permit for operation of Helideck 30 FPSO Indonesia Flag Using Indonesia Flag 31 FPSO Construction Approval for Construction of FPSO 32 Buoys for guidance Cargo Ships to FPSO Permit for placing Buoys at appointed points 33 Stipulation on Special Terminal location Location permit respectively for onshore jetty (if any) and the FLNG as Special Terminal
  7. 7. No PERMIT/LICENSE DESCRIPTION PURPOSE 34 Construction Permit for Special Terminal Construction permit respectively for onshore jetty (if any) and the FLNG as Special Terminal 35 Operation Permit for Special Terminal Operation permit respectively for onshore jetty (if any) and the FLNG as Special Terminal 36 Working Permit for Under Water work All underwater work shall have permit from Government 37 Dispensation for using Foreign Flag Vessel for Drilling Activities (IzinPenggunaanKapalAsing) Dispensation for using Category C and B Vessel 38 Dispensation for using Foreign Flag Vessel for Installation/Commissioning Activities (IzinPenggunaanKapalAsing) Dispensation for using Category C and B Vessel 39 Permit for Marine Telecommunication Marine Communication 40 Operation Permit Permits for Operation of Crew board, vessel, etc 41 Ground Aviation Radio Station Permits for Ground Radio for Flight 42 Dredging works permit Special Terminal Construction 43 Operation Worthiness Permit for Vessel (Surat IzinLayakOperasi) Permit for Vessel for Operation in Oil and gas Area 44 Special Vessel Operation Permit/SIOPSUS Permit for FLNG as a vessel to operate within Indonesian water, as facility supporting the oil and gas operation 45 LNG Tank Volume Calibration Certificates Permits for meeting regulations requirements in fiscal/Measurement Unit System 46 Custody Transfer Measurement System Usage Permit - Calibration Permits for meeting regulations requirements in fiscal/Measurement Unit System 47 Custody Transfer Measurement System Usage Permit-Calibration for International Trade Permits for meeting regulations requirements in fiscal/Measurement Unit System 48 Producer Imported License (API-P) For importation of materials/Goods 49 Master List Capital Goods Permit for Import of Goods and Materials (Exception of Import Duty) 50 Import Goods Plan (RIB) Permit for Import of Goods and Materials (Exception of Import Duty) 51 Approval of Foreign Commercial Loan (PKLN) In respect of foreign loan if the Project is project financed 52 Working Permit for Foreign Personnel- INPEX Employee (RPTKA & IMTA) Permit as Basis for Department of Justice to issue KITAS for Foreign Worker 53 Working Permit for Foreign Personnel for Contractor's (RPTKA & IMTA) Permit as Basis for Department of Law and Human Rights to issue KITAS for Foreign Worker 54 Certification of Lifting Equipment in Onshore.(Non Oil and Gas Plant) Permit for using lifting Equipment. 55 Radio Communication Permit (Izin Pita SpektrumFrekuensi Radio) Permits for Usage of Marine Radio 57 Principle Permit of Special Telecommunication Arrangement Permit Permits for Special Telecommunication 58 Radio and Communication Frequency Permit For Using During Construction/Commissioning Permit for Walkie Talkie Permit 59 Permit to use, Store and Transport of Radioactive materials To comply with Government Regulation Survey & Mapping Mapping of the Project Location into Indonesia Chart License Officer (LO) Permit to use L.O personnel during construction, installation work 62 Survey Vessel Permit Permit for using Survey Vessel and survey activities 63 Clinic Facility License Permit for Clinic Usage 64 Pharmaceutical Storage License Permit for Pharmaceutical/Medicines
  8. 8. No PERMIT/LICENSE DESCRIPTION PURPOSE 65 Occupational health and safety (company doctors, paramedic officials, and expatriate physician) Permit for paramedics activities 66 Security Clearance Permit for Entering Indonesia Water 67 Explosive Materials Production, Procurement, Storage, and Distribution Permit Explosive material permit 68 Building Permit for Base Camp (IMB) Permit for Building both Temporary and Permanent 69 Land Acquisition (IzinLokasi) Permit for Building both Temporary and Permanent Facilities 70 Land Ownership (HakGunaBangunan) Land Right Used 71 Permit to Use Power Generator (IzinOperasi) For Utilization of Power if INPEX Will provide Own Power Generator 72 Letter of Recommendation from Regional Government (BUPATI) for Special Terminal Recommendation Letter for Special Terminal 73 Permit to Use Heavy Equipment from Public Works Office-Regional Government (KABUPATEN) Permit for using Heavy Equipment 74 Compulsory Report of Company's existence employee in the region Reporting on current number of National and foreign employee working in the region 75 Permit for doing business in the region To register INPEX office in the region 76 Compulsory Report of Company's existence employee in the region Reporting on current number of National and Working Permit of foreign employee that are working in the region 77 Building Permit (IMB) Explosive & Detonator Storage 78 Building Permit (IMB) Construction of Fuel Storage 79 Building Permit (IMB) Construction of Hangar & other buildings (Permanent & Temporary) 80 Permits of Ground Water Extraction Usage of Ground Water 81 Permits of Surface Water Usage Surface Water 82 Building Permit (IMB) Clinic Facility, Dining & Kitchen Facility 83 Construction Permit Infrastructure Construction (Public Road & Drainage) 84 Site Representative Office For Rep office before FEED Phase (Temporary ) 85 Letter of Domicile of INPEX/Contractor Permit for domicile 86 Landing Permit for Heavy Duty Construction Equipment Permit for usage of Heavy Equipment 87 Fuel Allocation for Project Purpose/Annual Allocation Letter of approval for supplying fuel for INPEX On Shore operation

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