FORMS - TABLE OF CONTENTS - Auckland Airport



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| Permit to Work No: | | | A list of authorized Auckland Airport permit issuers is available from|

| | | |the persons named in 3 or 4 below. |

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Auckland Airport Staff or Lessees/Concessionaires and their contractors must complete sections 1 & 2 of this form, and scan or email it to the relevant Auckland Airport Authorising Manager for approval in Section 3. Then the form shall be sent to the relevant Auckland Airport ESS Rep AT LEAST 24 HOURS prior to the requested commencement date for final ESS authorisation.

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| |Auckland Airport STAFF or LESSEE/CONCESSIONAIRE INITIATING WORK to complete this section | |

|1. | | |

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| |Name: | |Company: | | |

| | | | | |

| |ph: | |mob:|

| |Work description: | | |

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| |Building: | |Location: | | |

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| |The contractor has been advised of Security, Fire Safety & Evacuation orders relevant to the area of work and that on the sound of evacuation alarms they | |

| |shall evacuate from the building. All known significant health & safety hazards have been identified to the contractor. The | |

| |Contractor/Lessee/Concessionaire is familiar with all contents of the Auck Airpt Contractors' Guidelines: | |

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| |SIGNED BY INITIATOR: | |Date: | | |

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| |CONTRACTOR to complete this section | |

|2. | | |

| | | | | |

| |Name: | |Company: | | |

| | | | | |

| |Ph/cell: | |email: | | |

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| |Type of equipmt to be used: | | |

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| |Job commencement date: | |Completion date: | | |

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| |Work hours: (start time) | |(finish time): | | |

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| |Will hot work be required? (enter Yes or No - see 7-8 overleaf): | |Hot work No: | | |

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| |Note re Hot Work: A list of authorized Auckland Airport permit issuers is available from the persons listed in 3 or 4 below | |

| |Will structural penetration be required? (enter Yes or No): | | |

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| |Will smoke detector isolation be required? (enter Yes or No or NA): | |Isolation No: | | |

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| |Will electrical isolation be required? (enter Yes or No or NA): | |Isolation No: | | |

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| |Will sprinkler isolation be required? (enter Yes or No or NA): | |Isolation No: | | |

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| |Will water shutdown be required? (enter Yes or No or NA): | |Isolation No: | | |

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| |Will ground penetration be required? (enter Yes or No or NA): | |Permit No: | | |

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| |Will traffic management be required? (enter Yes or No or NA): | | |

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| |Will there be any risk of a fall? (enter Yes or No): | | |

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| |Will work in ceiling, wall, floor spaces or other confined spaces be required? (enter Yes or No): | | |

| | | | | |

| |Is there anyone who will work on this job who has NOT had an airport induction? (enter Yes or No): | | |

| | | | | |

| |Any “yes” answer above requires a Job Safety Analysis – is it attached? (enter Yes or No or NA): | | |

| | | | | |

| |Have you signed overleaf as accepting all terms listed in this form? (enter Yes or No): | | |

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| |Auckland Airport REPRESENTATIVE AUTHORISING WORK to complete this section | |

|3. | | |

| | | | | |

| |Name: | | |

| | | | | |

| |Is there any conflicting work in the area? (enter Yes or No): | | |

| | | | | |

| |Will other stakeholders be affected? (Yes or No; if yes, who?): | | |

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| |SIGNED BY AUCK AIRPT REP: | |Date: | | |

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continued overleaf

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| Permit to Work No: | | | A list of authorized Auckland Airport permit issuers is available from|

| | | |the persons named in 3 or 4 below. |

| | |

| | | | | |

| |Auckland Airport ESS REP AUTHORISING WORK to complete this section | |

|4. | | |

| | | | | |

| |Name: | | |

| | | | | |

| |Is there any conflicting work in the area? (enter Yes or No): | | |

| | | | | |

| |Will other stakeholders be affected? (Yes or No; if yes, who?): | | |

| | | | | |

| |Is ESS Rep willing to authorize this work to commence? (enter Yes or No): | | |

| | | | | |

| |cc form to Auck Airport representative who requested this work (ie, as named in 3 above) & Auck Airport Operations (ICR) | |

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| |SIGNED BY ESS REP: | |Date: | | |

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Auckland Airport shall retain completed Permit to Work forms for a period of one year from the date in Section 1 above.

Conditions of Work

1. All personnel working airside shall hold a valid Security Pass issued by Aviation Security.

2. The Contractor shall carry this ‘Permit to Work’ and all other relevant permits at all times and shall produce them whenever requested by an Auckland Airport representative or Avsec. Failure to produce this ‘Permit to Work’ or other permit upon request may result in the Contractor being instructed to leave IMMEDIATELY.

3. Work shall be carried out only in the location recorded herein.

4. Only companies with established Health & Safety Control Programmes may work on or in Auck Airport-owned premises. All Contractor’s staff must be fully trained in safe work methods and handling of hazardous materials.

5. Only qualified persons may undertake work on Auckland Airport property. All plumbers and all electricians must be registered. No work shall be carried out on, or changes made to, or any interference with any electrical, mechanical, plumbing or air conditioning plant or any other Auckland Airport equipment without Auckland Airport 's authority.

6. All access equipment (eg, scissor hoists, cherrypickers, etc) must be operated by persons trained to the current NZ standard/Operating Certification level, including training in use of safety harnesses. Anyone using Auckland Airport access equipment must use the current booking system.

7. No Hot Work shall be carried out unless Auckland Airport has issued an approved Hot Work Permit. NOTE: Hot Work means use of naked flame, creating sparks or creating temperatures that may result in the combustion of surrounding material.

8. If Hot Work or work creating dust will be done near Smoke Detectors, the detectors must be isolated & capped.

a. For hot work, submit the yellow Hot Work Permit in accordance with the Hot Work Procedures document (you must submit it on day of work, and a new form submitted at each shift change).

b. For Isolation of Smoke Detectors submit form 405.

9. Tools/equipment must NEVER be left unattended at any time and shall be removed prior to leaving work site.

10. The Lessee/Concessionaire and contractor must be familiar with:

a. Auckland Airport construction requirements;

b. Auckland Airport Contractors' & Tenants’ Guidelines;

c. Auckland Airport Safety Guide for Contractors.

11. Security access gates or doors shall be kept secure at all times.

12. All leads and power tools shall have current tested tags.

13. RCD's must be used at all times.

14. Good housekeeping standards must be adhered to at all times.

15. Contractors shall report any suspicious activity they observe to Monitoring on 256 8817.

16. Public are to be separated from the work area at all times, either by solid hoardings or presentable cones with solid horizontal barriers to be determined by AA Site Rep. Caution tape is not an acceptable solution.

17. Fire exits shall be kept clear and free from obstructions AT ALL TIMES.

18. Materials or equipment must NOT be taken on escalators or public lifts without permission.

19. Lessee’s/Concessionaire’s contractor may NOT carry out cabling through non-tenanted spaces. Reference/requests may only be actioned by the Auckland Airport Cabling Department.

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|I hereby certify I have read, understood and agree to abide by the “Conditions of Work” set out above: | |

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|SIGNED BY CONTRACTOR: | |Date: | | |

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