1. Project Information: (To be filled by initiator/originator) Project Name: Permit No.: Project Location: Requesting Contractor/Company 2. Permit Issuance Details: (To be filled by initiator/originator) THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE Description of Task: Detail of Surroundings: Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date: Weight of Load : Max Height of Lift: Max. Radius of Lift: Lifting Equipment ID/Registration No.: Crane Capacity (SWL) Lift shall not be carried out if the load chart capacity exceeds 80% (Capacity …………) Lifting Point Defined: ☐ Yes ☐ No Road Closure/ Isolation required: ☐ Yes ☐ No Underground services identified (if applicable): ☐ Yes ☐ No Load Centre of Gravity Calculated: ☐ Yes ☐ No 3. Lifting Operation Details: (To be filled by initiator/originator) Crane Operator Contact: Rigger-1 Contact: Rigger-2 Contact: Type of Lifting Crane: ☐ Mobile Crane ☐ Wheel crane ☐ Crawler Crane ☐ All Terrain ☐ Loader/Hiab Crane ☐ Excavator ☐ Elevated working Platform ☐ Mobile Concrete Pump ☐ All Winch ☐ Other : Lifting Crane Specification: ☐ Year of make (<25 years): __________ ☐ Lifting Capacity: __________ ☐ No. of rope fall wraps: ___________ ☐ SWL: ______________ ☐ Boom Reach: __________ ☐ Fly Jib Reach: ___________ ☐ Other(s): _____________ Type of lifting Gear(s): ☐ Chain Sling, No. Of Legs: ___________ Each Leg Capacity: ____________ SWL: ______________ ☐ Webbing Sling, SWL: ____________ ☐ Wire Rope, SWL: _____________ ☐ Lifting Beam, SWL: ___________ ☐ Shackle, SWL: _____________ ☐ Chain Blocks, SWL: ____________ ☐ Hook with latch, SWL: ___________ ☐ Eye Bolt/Nut, SWL: ____________ ☐ Other(s): _________________ 4. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Checks Yes-No-NA Checks Yes-No-NA Risk assessment/ method statement and Lifting Plan developed, approved and communicated? ☐ ☐ ☐ Crane outriggers fully extended and spreading pads in place ☐ ☐ ☐ Operatives are consulted and trained? ☐ ☐ ☐ All wheels are off the ground. ☐ ☐ ☐ Provision of vigilance supervision? ☐ ☐ ☐ SWL and radius indicators in working order with visual and audible warning ☐ ☐ ☐ Has the crane valid certification ☐ ☐ ☐ Wind indicator is fitted & in working order ☐ ☐ ☐ Has the lifting gears valid certification ☐ ☐ ☐ load(s) slung correctly by a competent rigger ☐ ☐ ☐ Riggers/slinger competent and certified ☐ ☐ ☐ Tag-line(s) are connected with the load ☐ ☐ ☐ Correct crane selected for the load(s) and radius ☐ ☐ ☐ Suspended Load slewing path is cleared from people and barricaded ☐ ☐ ☐ Ground suitable, even, firm and prepared ☐ ☐ ☐ Destination of load(s) is cleared and prepared sufficiently ☐ ☐ ☐ Safe means of access/egress provided

1. LIFTING WORK PERMIT
Page 1 of 2 Form # HSEQ-LWP (Rev 2 - Mar 23)
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Detail of Surroundings:
Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:
Weight of Load : Max Height of Lift:
Max. Radius of Lift: Lifting Equipment ID/Registration No.:
Crane Capacity (SWL)
Lift shall not be carried out if the load chart capacity
exceeds 80% (Capacity …………)
Lifting Point Defined: ☐ Yes ☐ No Road Closure/ Isolation required: ☐ Yes ☐ No
Underground services identified (if applicable):
☐ Yes ☐ No
Load Centre of Gravity Calculated: ☐ Yes ☐ No
3. Lifting Operation Details: (To be filled by initiator/originator)
Crane Operator Contact:
Rigger-1 Contact:
Rigger-2 Contact:
Type of Lifting Crane: ☐ Mobile Crane
☐ Wheel crane ☐ Crawler Crane
☐ All Terrain
☐ Loader/Hiab Crane
☐ Excavator
☐ Elevated working Platform
☐ Mobile Concrete Pump
☐ All Winch
☐ Other :
Lifting Crane Specification: ☐ Year of make (<25 years): __________
☐ Lifting Capacity: __________
☐ No. of rope fall wraps: ___________
☐ SWL: ______________
☐ Boom Reach: __________
☐ Fly Jib Reach: ___________
☐ Other(s): _____________
Type of lifting Gear(s): ☐ Chain Sling,
No. Of Legs: ___________
Each Leg Capacity: ____________
SWL: ______________
☐ Webbing Sling, SWL: ____________
☐ Wire Rope, SWL: _____________
☐ Lifting Beam, SWL: ___________
☐ Shackle, SWL: _____________
☐ Chain Blocks, SWL: ____________
☐ Hook with latch, SWL: ___________
☐ Eye Bolt/Nut, SWL: ____________
☐ Other(s): _________________

2. LIFTING WORK PERMIT
Page 2 of 2 Form # HSEQ-LWP (Rev 2 - Mar 23)
4. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Risk assessment/ method statement and Lifting
Plan developed, approved and communicated?
☐ ☐ ☐
Crane outriggers fully extended and
spreading pads in place
☐ ☐ ☐
Operatives are consulted and trained? ☐ ☐ ☐ All wheels are off the ground. ☐ ☐ ☐
Provision of vigilance supervision? ☐ ☐ ☐
SWL and radius indicators in working order
with visual and audible warning
☐ ☐ ☐
Has the crane valid certification ☐ ☐ ☐ Wind indicator is fitted & in working order ☐ ☐ ☐
Has the lifting gears valid certification ☐ ☐ ☐
load(s) slung correctly by a competent
rigger
☐ ☐ ☐
Riggers/slinger competent and certified ☐ ☐ ☐ Tag-line(s) are connected with the load ☐ ☐ ☐
Correct crane selected for the load(s) and radius ☐ ☐ ☐
Suspended Load slewing path is cleared
from people and barricaded
☐ ☐ ☐
Ground suitable, even, firm and prepared ☐ ☐ ☐
Destination of load(s) is cleared and
prepared sufficiently
☐ ☐ ☐
Safe means of access/egress provided? ☐ ☐ ☐ Load rating chart for the crane is available ☐ ☐ ☐
Crane is set-up away from excavation ☐ ☐ ☐ Communication aid available (radio device) ☐ ☐ ☐
Crane swing radius area is free from overhead
cable/ structure or other cranes
☐ ☐ ☐
Has the operator have a valid 3rd
party
certificate and license?
☐ ☐ ☐
Proper barricade and signage are posted? ☐ ☐ ☐ Others (specify): ☐ ☐ ☐
5. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives,
and I consider them competent to do it safely.
Initiator/Originator
Name:
Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):
6. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
7. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator: Designation:
Signature: Date /Time
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator: Designation:
Signature: Date /Time