The Applicant shall complete Sections 1 and 2, sign Section 3 and submit to the DPA Wharf Manager for approval.

Permit Issuer Checklist has been reviewed with the permit requestor prior to the commencement of work

DPAUse

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Permit No.:

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EDOC No.:

SECTION 1: General

Applicant Company: / Phone: / Fax:
Company performing works: / Phone:
Company representative in charge of works:
Person in attendance: / Phone:
Permit Valid From: / (Hrs) / Date: / To: / (Hrs) / Date:

SECTION 2: Work Details, Precautions & Conditions

2.1 Description of Work

DCW / DBLB
Location of Work: (Specific)
Description of Work:
(type/personnel/equip)

2.2Permit Checklist

Does the work involve: / Y / N / If yes obtain:
  1. Excavation, cutting, drilling, penetrating ground by more than 100mm, or drilling into walls?
/ Dig Permit
  1. Abrasive blasting?
/ Abrasive Blasting Checklist
  1. Any space not designed for normal work, where rescue may be difficult eg roof spaces, underneath buildings, within tanks?
/ Confined Space Permit
  1. High Voltage (HV) incl entry to any signed HV space or cabinet. 240V electricity which cannot be isolated. Sewer or sewage systems, gas or high pressure water?
/ Services Permit
  1. Height greater than 2.4m involving risk of an unrestrained fall or any work at a height of less than 2.4m involving risk of a fall from one level to another?
/ Working at Heights Permit
  1. Work within 3 m of road within Port and KBIE requiring decreased speed limits or use of safety barriers or has the potential to impact traffic flow?
/ Traffic Permit
  1. All lifts over 20t on DCW or more than 1.5t / m2 on DBLB?
/ Heavy Lift Permit
  1. Handling dangerous goods (DG) incl DG transported onto or off DPA land, transported onto DCW or DBLB, loaded onto or off vessels, or in transit on vessels in Port?
/ Dangerous Goods Permit
  1. Removal of native vegetation, work in or near a previously undisturbed area or within a National Heritage Listed area?
/ Environment and Heritage Permit
  1. Diving within 200m of DPA wharf facilities - DBLB, DCW, ALF, HLO, Barge Ramp?
/ Diving Permit
  1. Loads greater than 4.3m high, 2.4m wide, 19m long or over 42.5t?
/ Oversized Load Permit

2.3Permit Conditions

Y / N / N/A
  1. Hot Work is prohibited on a Total Fire Ban day - check

  1. Bunkering will not be carried out on the same vessel while Hot Work Permit is active.

  1. Dangerous Goods will not be handled on the same vessel while Hot Work Permit is active.

  1. Ship’s Hot Work Permit has been issued.

  1. JHA / JSA / JSEA / WMS / SWI has been prepared for the works, if not, provide explanation:

  1. If abrasive blasting is occurring, please complete the Abrasive Blasting Checklist (SHEQ-SYS-F-192) and attach the Checklist to this Permit.

  1. Combustible materials have been removed from the work area or made safe.

  1. Oxy/Acetylene bottles are to be upright and properly secure at all times.

  1. Fire Extinguisher is to be on standby at all times.

  1. If required, a fire watch has been organised, fire equipment laid out ready for use, or the fire pump or fire brigade is on standby.

  1. Barricades and warning signage are to be in place at all times.

  1. Equipment is isolated electrically.

  1. Hoses, electrical leads and equipment have been tested/tagged in accordance with Australian Standards.

  1. Applicant is aware of location of:
  • Ammonia pipeline and equipment;
  • bunkering points, fuel lines, fuel shut off points;
  • fire hoses, mains and water outlets;
  • fire alarms; and
  • UHF radio communications to Port Communications.

  1. The work area has been checked with a combustible gas indicator.

  1. Ventilation and wind direction are suitable for works.

  1. The Company representative in charge of works/ person in attendance agrees to advise all team members of Permit Conditions.

  1. The Company representative in charge of the works acknowledges that any change in the nature, location, duration or timing of the works will void this permit and a new permit must be applied for.

  1. Other special conditions / precautions:

2.4Required Permit Documentation

Y / N / N/A
  1. JHA/JSA/JSEA /WMS/SWI.

  1. Ship’s Hot Work Permit.

SECTION 3: DPA Receipt, Permit Approval & Permit Acceptance

If the Applicant is the Company which will carry out the work, by applying for this permit it makes the following warranties, undertakings and acknowledgements:
  1. The Applicant warrants that it understands the nature of the work permitted by the permit and risks associated with it, has sufficient competence to carry out the work andaccepts responsibility (including occupational health and safetyresponsibility)for the work.
  2. The Applicant undertakes to notify DPA as soon as possible afterit identifies any issue which would prevent the work from being carried out safely, and to liaise with DPA to allow the work to be carried out safely.
  3. The Applicant acknowledges that the issuing of this permit does not constitute approval by the DPA of the work or occupational health and safety procedures in relation to the carrying out of the work.
  4. The Applicant warrants that, where it has particular expertise or technical knowledge with respect to the work permitted by the permit, it accepts that it, and not DPA, exercises control over that work and is responsible for any occupational health and safety obligations arising from that work.

If the Applicant is not the Company which will carry out the work, by applying for this permit it makes the following warranties, undertakings and acknowledgements:
  1. The Applicant warrants that it understands the nature of the work and risks associated with it.
  2. The Applicant undertakes to take whatever steps are required to ensure that the Company which will carry out the work understands the nature of the work and risks associated with it.
  3. The Applicant warrants that the Company which will carry out the work has sufficient competence to carry out the work andaccepts responsibility (including occupational health and safetyresponsibilityfor the work.
  4. The Applicant undertakes to take whatever steps are required to ensure the Company which will carry out the work notifies the DPA as soon as possible afterit identifies any issue which would prevent the work from being carried out safely and liaises with the DPA to allow the work to be carried outsafely.
  5. The Applicant undertakes to take whatever steps are required to ensure the Company which will carry out the work understands that the issuing of this permit does not constitute approval by the DPA of the work or occupational health and safety procedures in relation to the carrying out of the work.

Applicant’s Authorised Representative:
(Name) / (Signature) / (Date)
(Title)
Permit Authoriser:
(Name) / (Signature) / (Date)
Notifications: / Wharf Manager / Y N / Environment / Y N / Safety / Y N / Other:
Maintenance / Y N / Engineering / Y N / Security / Y N
SECTION 4: Completion
The work has been completed and all persons who had a role in carrying out the work, materials and equipment have been withdrawn.
Authorised Representative of Applicant Signed / OR / Company in Charge of Works Signed
(Name) / (Signature) / (Date)
Permit Authoriser:
(Signature) / (Date)
Issued Date: 22.11.10 / Rev No: 6 / Page: 1 of 3