Permit Number:
Part A: Project Details
To be completed by permit issuer in consultation with contractor in charge of work.
Project:
Project Number:
Description of Work:
Location:
Contractor:
Name of Contractor in Charge of Work: / Phone:
Date of Issue: / …… / …… / …… / ……. : ……. ☐am ☐pm
Estimated Completion Date: / …… / …… / …… / ……. : ……. ☐am ☐pm
Part B: Risk Assessment
Safe access
1 / Safe access to work areas for all operations in place? / ☐Yes / ☐No / ☐N/A
2 / Firm level ground for scaffold/mobile access tower/ ladder etc.? / ☐Yes / ☐No / ☐N/A
3 / Overhead Services/Obstructions have been identified and communicated? / ☐Yes / ☐No / ☐N/A
4 / Overhead Services/Obstructions have been isolated? / ☐Yes / ☐No / ☐N/A
5 / Safe method of removal of waste identified? / ☐Yes / ☐No / ☐N/A
Fall Protection
SCAFFOLD Ladder elevated Work Platform Fall RESTRAINT
1 / Are you qualified to undertake work? / ☐Yes / ☐No / ☐N/A
2 / Is area barricaded? / ☐Yes / ☐No / ☐N/A
3 / Scaffold in place and certified? / ☐Yes / ☐No / ☐N/A
4 / An appropriate fall restraint system/arrest system in place? / ☐Yes / ☐No / ☐N/A
5 / Has harness been inspected? / ☐Yes / ☐No / ☐N/A
6 / A rescue plan has been prepared? / ☐Yes / ☐No / ☐N/A
7 / Is harness within the manufacturer’s recommended inspection (six months maximum) date? / ☐Yes / ☐No / ☐N/A
8 / Has Fire Rescue have been notified of the work? / ☐Yes / ☐No / ☐N/A
9 / Are weather conditions acceptable? / ☐Yes / ☐No / ☐N/A
10 / Is there any risk of falling objects? / ☐Yes / ☐No / ☐N/A
11 / Are there any overhead services adjacent to the work area? / ☐Yes / ☐No / ☐N/A
12 / Is the edge protection/toe boards in place on scaffold? / ☐Yes / ☐No / ☐N/A
13 / Are tools and equipment secured against falls? / ☐Yes / ☐No / ☐N/A
14 / Is a safety net required? / ☐Yes / ☐No / ☐N/A
15 / Are tools and equipment secured against falls? / ☐Yes / ☐No / ☐N/A
16 / Other Requirements:
Part C: Sign-on & Agreement by Contractors Performing the Work
Contractor in Charge of Work:
I, ______understand the above Safe Work Requirements and agree to comply with this permit.
I confirm I have verified the above information is correct and have ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the permit information has been explained to all workers involved.
Signature:______Date: ____ / _____ / ______
Other Team Members Performing the Work: - I have reviewed the safe work procedures submitted for the job and agree to comply with this permit.
Name: / Signature:
Part D: Work Authorisation To be completed by permit issuer.
I hereby authorise the persons nominated above to perform the work specified in Part C of this Permit.
I have also validated all contractors licenses / certificates of competency required for the relevant activities they have been engaged for
Name: / Signature:
Part E: Work COmpletionTo be completed by permit issuer.
Date of Work Complete: / …… / …… / …… / ……. : ……. ☐am ☐pm
Date Permit Closed: / …… / …… / …… / ……. : ……. ☐am ☐pm
Name: / Signature:
QAC Document:QAC-I-FRM-005Page 1 of 2
Queenstown Airport Corporation Internal Use OnlyVersion: 1.0