Permit to Work - Master Document



|This document must be lodged with, and approved by, the Albany Port Authority before contractors can conduct non-routine work on site. Non-routine work |

|performed by contractors must be planned so that hazards are identified and control measures put in place to protect personnel, plant and equipment and the|

|environment. Please refer to the Contractors Handbook to clarify the meaning of Non Routine. |

|Non-routine work may include, but is not limited to: excavation, hot work, diving operations, construction, scaffolding, confined space work, abrasive |

|blasting and any work under the berths. |

|Please contact the APA if you are unsure as to whether you need a permit. |

Section 1: Application Details

|Contractor’s Name | |Position | |

|Company Name | |Date | |

|Company Phone# | |Mobile | |

|APA Representative | |Work Order | |

Section 2: Description of Scope of Work (include times and location)

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Section 3: Checklist of Permits or Procedures to be completed

| | Please tick the appropriate boxes to show consideration of necessary procedures, refer to Contractors Handbook if unsure | |

|Procedures |Yes |No |

|1 | |Isolation & Tag Out Procedure? | | |

|2 | |Job Safety Analysis (or equivalent) Completed? | | |

|3 | |Port Inductions Completed? | | |

|4 | |All staff have MSIC’s as required? | | |

|5 | |Will Traffic Management be required? | | |

|Activity | |

|1 | |Confined Space – Contractor to provide detailed plan as per Australian Standard 2865-2009 | | |

|2 | |Excavation – see APA Excavation Permit | | |

|3 | |Hot Work – See APA Hot Work Permit | | |

|4 | |Working at Heights - APA Working At Heights Permit | | |

|5 | |Crane Lift on or onto a berth, within16m of berth sheet piling, or EWP on a berth – APA Lift Permit (please contact APA | | |

| | |to confirm requirements) | | |

|6 | |Crane Lift – non berth related – no additional permit required | | |

|7 | |Diving – See APA Dive Permit | | |

|8 | |Abrasive Blasting – See APA Blasting Permit | | |

|9 | |Working From a Vessel – See APA Working Afloat Permit | | |

|10 | |Scaffolding – See APA Scaffolding Permit | | |

|11 | |Vessel Fumigation – See APA Fumigation Permit | | |

Section 4: Applicant’s/Contractor’s Regulatory Requirements

| | |N/A |Yes |No |

|1 |High Risk Work licences – e.g. Forklift, EWP, Rigging, Crane, etc (Individual Operator) | | | |

|2 |Heavy Vehicle Licences (Individual Operator) | | | |

|3 |Classified Plant & Heavy Vehicle valid certificates/registration | | | |

|4 |Valid Insurances – Public Liability & Workers Compensation | | | |

|5 |MSDS – HAZCHEM | | | |

|6 |PPE appropriate for Scope of Work (APA Mandatory PPE is a minimum) | | | |

|7 |Marine Qualifications (Coxswain, Restricted Coxswain, Master Class 5 etc) | | | |

|8 |Other (e.g. working at heights) | | | |

Section 5: Contractor Representative Statement of Acknowledgement

|I acknowledge the requirements of the Albany Port Authority to identify and control risks and work in a safe manner at all times. I confirm the company |

|has satisfactory documented safe systems of work in place and that all permits and licences required are in order and understood. |

|Company Representative Signature | |Date & Time |

|Position in Company | | |

Section 6: APA Representative Statement of Acknowledgement (APA Use Only)

|I am satisfied that the contractor information provided to me is sufficient to show that the contractor has a system in place to fulfil their legal |

|obligations to conduct works in a safe manner. This Permit to Work is approved subject to any conditions listed in Part 7 below. |

|APA Representative Signature | |Date & Time |

|Position | | |

Section 7. Specific Conditions / General Comments

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|Note: The applicant must hold a copy of this form at all times while on site. |

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|The APA may withdraw this permit at any time if unsafe practices are observed. |

Section 8: Notifications

|Engineer | |Maintenance | |

|Safety | |Environment | |

|Security | |Pilots | |

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UNCONTROLLED COPY – Check Intranet or Registers for current version

CONTROLLED DOCUMENT WHEN PRINTED RED

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