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Permit to Work ______For Infrastructure/Utility Works in Rail-Protection-Zone (Filled out by Qatar Rail) Company Management System

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Permit to Work ______For Infrastructure/Utility Works in Rail-Protection-Zone (Filled out by Qatar Rail) Company Management System QR-PERMIT Ref. # Qatar Rail Permit to Work ____________________ for Infrastructure/Utility Works in Rail-Protection-Zone (Filled out by Qatar Rail) Company Management System First Submittal Renewal Previous QR Permit Ref. # _______________________________ Contractor / Applicant: Contractor Contract No Building No. Street No. Street Name: Full address Zone No. Stamp/signature Telephone/Fax Email The Contractor/Applicant certifies that: Print name: He/she fully understands the documentation associated with this work activity, the hazards, the precautions required, his/her obligations, and the procedures to carry out the work in relation to the rail interface, He/she will provide access/egress for Qatar Rail to their land & work sites at all times and during all phases of the work. Date: The workforce undertaking the work activities are fully briefed and equipped and understand the safety and emergency procedures to be followed and are competent. Others. Also refer to terms & conditions. Name Person in Charge Email Title Mobile No PERMIT DURATION (maximum 3 months) WORK LOCATION (area, zone, street/no.) FROM DATE / TIME: TO DATE / TIME: DR No. RO No. Project / Scheme: Work Description TRIAL HOLE/BORE HOLE EXCAVATION LAYING CABLE(S) ELECTRICITY OHL LAYING PIPELINES PRESSURISED PIPE DRILLING WORKS FOUNDATIONS TUNNELING / PIPE JACKING PERMANENT CIVIL CONSTRUCTION BUILDING DEMOLITION TEMPORARY INSTALLATIONS (LESS THAN 6 MONTH) DEWATERING OTHERS Type and Description of Work: Applicant’s Client Applicant’s Consultant Stamp/signature Stamp/signature Name Name Title Title LEADING EXCELLENCE │CMS Ref.: TM-215-F06, 04/02/19, Rev. 3.0 Page 1 of 3 QR-PERMIT Ref. # Qatar Rail Permit to Work ____________________ for Infrastructure/Utility Works in Rail-Protection-Zone (Filled out by Qatar Rail) Company Management System QATAR RAILWAYS (QR) COMPANY (APPROVING ENTITY) Red Line North EAG Red Line North UG Red Line South UG Red Line South EAG Green Line EAG Green Line UG Gold Line UG Gold Line EAG Blue Line UG Black Line UG Long Distance Commuter Line Lusail LRT Phase _________________________________________ LOT / CORRIDOR ___________________________________________ QR CONTRACTOR RKH QITARAT - SERVICE PROVIDER ENDORSEMENT (1) I have reviewed, assessed and considered the intended work and my comments on the submission are shown below. Provided these comments are adequately addressed I hereby endorse the acceptance of the intended third party work. Comments / conditions: (use separate page, if required) Stamp/signature Name Title QR PMC PROGRAM MANANGEMENT CONSULTANT SERVICE DELIVERY DEPT. (RAILWAY OPERATOR) ENDORSEMENT (2) I have reviewed, assessed and considered the intended work and my comments on the submission are shown below. Provided these comments are adequately addressed I hereby endorse the acceptance of the intended third work. Comments / conditions: (use separate page, if required) Stamp/signature Name Title QR GOVENMENTAL INTERFACES & PERMITS DEPARTMENT (3) I accept that, so far as can reasonably be ascertained from the information submitted, the relevant comments and conditions stated herein including the associated documents have been complied with properly. QR GENERNAL CONDITIONS DETAILED DESIGN DRAWING(S) COMPLIANCE CERTIFICATE DR – DESIGN REVIEW TRAFFIC DIVERSION & ACCESS PLAN LETTER OF AUTHORISATION (CONTR./CR/ID) RO – ROAD OPENING PERMIT METHOD STATEMENT / RISK ASSESSEMENT UNDERTAKING&LIABILITY LETTER/ INSURANCE INTERFACE DRAWING EMERGENCY/MONITORING/DEWATERING PLAN INTERFACE CONTROL FORM / OTHERS Comments / conditions: (use separate page, if required) Stamp/signature Name Title VALID FOR MAXIMUM 3 MONTH LEADING EXCELLENCE │CMS Ref.: TM-215-F06, 04/02/19, Rev. 3.0 Page 2 of 3 QR-PERMIT Ref. # Qatar Rail Permit to Work ____________________ for Infrastructure/Utility Works in Rail-Protection-Zone (Filled out by Qatar Rail) Company Management System Terms & Conditions: 1. A Qatar Rail (QR) Permit to Work (PTW) to be filled out and submitted for every Railway Party (i.e. QR contractors, service provider, etc.) interfacing with the Third Party Intended Work. refer to QR contact list: QR Departments, QR Contractors, QR Operator & Service Provider 2. (1) If no Qatar Rail contractor is awarded, then the Qatar Rail Civil Department to sign. 3. (2) If no Qatar Rail PMC contract is awarded, then the Qatar Rail Alignment Department to sign. 4. The QR Governmental Interfaces & Permits Department can replace/overrule Endorsement (1) & (2). 5. The applicant must submit all relevant documents. Additional comments / conditions can be attached separately. 6. All work is at the applicants risk and responsibility. 7. Qatar Rail representatives have the right to STOP WORK if any violation of the submitted documents occurs of safe working practices are compromised. 8. Contractor must apply for the Qatar Rail Permit to Work 10 working days before starting the work. 9. Contractor must submit a QR approved & valid RO permit (construction NOC). 10. Contractor must submit all associated documents, proof of coordination with the contractors of active rail projects, Qatar Rail, the PMC or any other related department of Qatar Rail. Assessment and monitoring reports for (movements/settlements, vibration, noise/dust, etc.) as required by Qatar Rail. 11. The Rail Operator/Service Provider access- and operational requirements to be complied with. 12. All submitted documents must reflect the Qatar Rail interface and must match previous submissions. 13. The applicant must reflect the Qatar Rail interface in the method statement and risk assessment specifically for the intended works and the site specific conditions. 14. Any damage, partially or totally, to Qatar Rail assets shall be reported to Qatar Rail immediately. All costs will be at the applicants account. 15. All costs to carry out the intended works (design & construction) are at the applicants account. 16. The Qatar Rail approval of the intended works is for the duration of the works as specified in this permit but not longer than 3 month. 17. If the intended work of the applicant requires more than 3 month or the RO permit has expired, a new Permit to Work shall be submitted. 18. Any change to the reviewed documents or design or method of work is required to be notified to Qatar Rail immediately and renders this document as invalid. A new application has to be submitted. 19. The applicant shall comply with the law, rules and regulations of the State of Qatar as well as Qatar Rail & Operational rules & regulations & guidelines. 20. Any attachments and related documents to this PTW-document are part of the Permit to Work. 21. The QR General Conditions apply. Access & movement around metro stations (assets) 1. The applicant shall implement active measures for any proposed activities that all access/egress to the Metro station is and Emergency access is safeguarded and protected including unrestricted pedestrian traffic 2. This includes obtaining approval from Qatar Rail for temporary traffic- & pedestrian management schemes. QR Inspections (QR appointed representatives) 1. Qatar Rail reserves the right to carry out site inspections announced and unannounced. Access shall be granted to Qatar Rail representatives. 2. For works with direct physical interfaces with Qatar Rail assets or land an inspection/hand-over to be arranged and fully conducted. 3. The approved permit shall be available on site at all time and readily available to Qatar Rail on request. Work Completion 1. As built drawings and relevant quality documentation to be submitted to Qatar Rail. 2. On completion of work Qatar Rail must be notified and respective Qatar Rail assets to be formally handed over. The applicant certifies that the information contained in this application is true and complete. The applicant confirms to undertake as follows: 1. Not to commence the proposed construction works prior to obtaining: (a) All relevant Authority and Government consents, permissions and approvals for the works. (b) The issuance of a Permit by Qatar Railways Company. 2. To perform the works strictly in accordance with: (a) The Permit issued by Qatar Railways Company; Law 10 of 2014 (also Ministerial Circular-6-2018 Circular no. (6) of 2018). (b) All conditions stipulated in this document and related documents by Qatar Railways Company and their representatives. (c) All authority and government consents, permissions or approvals. 3. Not to vary the works without obtaining a Permit from Qatar Railways Company. 4. To implement the construction works in accordance with all approved specifications and to take responsibility for all construction safety matters. The applicant to comply with the following: 1. Show the Permit to any Qatar Rail Inspector/ staff upon request. 2. Work only within the site boundaries as stipulated 3. Carry out all works in compliance with the instructions from Traffic Department; do not block traffic/pedestrian routes without providing save & secure alternatives. 4. Create protective barriers around the site to guarantee the safety of the public & adjacent properties. 5. Not store any building materials or equipment outside the site boundaries. 6. Not excavate sewage utilities outside the site boundaries. 7. Not to mix building materials on the sidewalks or the public roads. 8. Clean the site, sorting remnants outside city boundaries and then transfer them to sites assigned by MMUP. 9. In case of demolition, obtain the approval from authorities to coordinate cutting utilities services (if required). 10. Not allow storage of any hazardous materials on the site, unless approved. 11. Ensure that all groundwater is pumped in accordance with PWA & MME guidelines and requirements. 12. Excavate any trial pits and carry out any surveys required to ascertain the extent of existing utilities. Use Cable Avoidance Tool CAT & Signal Generator GENNY. 13. Be responsible for any violations. Any violation of one or more of these conditions shall invalidate the Permit. 14. It is mandatory to present detailed drawings/methods/and monitoring reports to obtain demolishing permits. LEADING EXCELLENCE │CMS Ref.: TM-215-F06, 04/02/19, Rev. 3.0 Page 3 of 3 .
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