ReviewDate:01/07/2018
The work at heights permit will need to be completed before any employee, contractor or site visitor may be allowed to access any roofs on GPNSW properties. This permit is valid for the time specified on the permit and must be
- Completed by the person performing the work prior to commencement of any work
- Used in conjunction with a Risk Assessment, SWMS or Safe work instruction
- Checked by the GPNSW Representative prior to work commencing
- Carried and produced/displayed when required
- Provided to the GPNSW Representative on completion of work for sign off
Part A Work Details
Name of permit requestor / Business name
Contact Number / Date of work
Location of work- Building
Description of work
Reason why access required
Permit validation period / From Date: / / Time:____am/pm / To Date: / /Time:____am/pm
GPNSW Authorised Representative / Name / Permit Number from objective
Position
Safety Checklist-Contractor to complete
Ladders
Rails, rungs, steps, ropes, stays, braces, hinges and feet all checked and OK / ☐Yes ☐No ☐N/A
Roofs
Crawling boards in place
Safety harness used
Perimeter protection in place / ☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
Scaffolding
Designed constructed and examined in accordance with statutory regulations
Copy of examination report held / ☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
Fall restraint/arrest
Used above 3 metres
Inspected and checked prior to use
Secured to correct anchor points
Persons trained in use / ☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
Elevated work platform
Positioned in a safe stable manner
Persons operating equipment have necessary tickets or permits / ☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
Ensure work is carried out in such a manner that it would not endanger people or cause damage to the equipment/building
Are cordoned off with warning signs/ribbon/tape
Maintain good housekeeping at all times
Debris generated disposed off from site immediately / ☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
☐Yes ☐No ☐N/A
Part B Declaration
I have carefully reviewed the hazards inherent in the intended task and taken into account the factors noted above and I am confident the task can be carried out safely. I and/or my representative agreed to abide to these requirements
Contractor / Name / Signature / Date
I am satisfied myself that the contractor has taken into account all safety hazards and that may impact on the safe execution of the work and I authorise the above signed to complete the work at the times stated above
Authorised GPNSW Representative / Name / Signature / Date
This permit is valid until pm on the date of issue or completion of the task, whatever is earlier
Cancellation/completion of permit
Permit cancelled/returned by / Name / Signature
Cancelled returned at / Date / Time
Reason for cancellation
Final Sign off
The worksite has been inspected by me at the cancellation/completion of the work at heights and declared safe for normal operations to resume.
Name / Signature / Date
Custodian: WHS Manager / Uncontrolled copy when printed / ©GPNSW
Approved by: Place Management / Version: 1.1
Number: SMS-02-FM- A1175700 / Page 1 of 2