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    Working at Height Permit

    Uploaded by

    k.bosano
    This document is a working at height permit for a company. It summarizes the work to be undertaken, any other applicable permits, and requires declarations from both the permit receiver and issuer. The receiver must declare they are competent for the work and have identified all hazards. An emergency response plan must be documented. Both parties must validate the permit details and sign off. The permit can be suspended and revalidated as needed.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Working at Height Permit

    Uploaded by

    k.bosano
    15 views1 page
    This document is a working at height permit for a company. It summarizes the work to be undertaken, any other applicable permits, and requires declarations from both the permit receiver and issuer. The receiver must declare they are competent for the work and have identified all hazards. An emergency response plan must be documented. Both parties must validate the permit details and sign off. The permit can be suspended and revalidated as needed.

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    working_at_height_permit

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    This document is a working at height permit for a company. It summarizes the work to be undertaken, any other applicable permits, and requires declarations from both the permit receiver and issuer. The receiver must declare they are competent for the work and have identified all hazards. An emergency response plan must be documented. Both parties must validate the permit details and sign off. The permit can be suspended and revalidated as needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    15 views1 page

    Working at Height Permit

    Uploaded by

    k.bosano
    This document is a working at height permit for a company. It summarizes the work to be undertaken, any other applicable permits, and requires declarations from both the permit receiver and issuer. The receiver must declare they are competent for the work and have identified all hazards. An emergency response plan must be documented. Both parties must validate the permit details and sign off. The permit can be suspended and revalidated as needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    An Auckland Council Organisation

    AA/JSA/SOP Ref #: Permit #


    Working at height permit Company name

    Summary of work to be undertaken


    Detail only the work to which this permit applies

    Do other permits apply to this activity? Refer to the job safety analysis form (JSA)
    Confined Hazardous Excavations Safety device Explosive Atmosphere Other
    Hot work
    space entry Energy ≥ 1.5 metres impairment Area (EEHA) (specify)

    Declaration by permit receiver

    • I am competent to identify and manage the risks connected • I have inspected the work location and identified
    to this work permit (evidence of training provided) Yes No all hazards Yes No

    • The work will not impact neighbouring areas and


    • The work area is defined with barriers/signs Yes No increase any current risk level Yes No

    • If there are any of the following hazards in the work area, or an equivalent hazard, the required controls to eliminate or
    minimise the risk have been established: Brittle surfaces, skylights, internal gutters, trip hazards, structural instability, Yes No
    single skin canopy, hazardous material/dust, overhead hazards
    • All workers are trained in working at height and
    • Emergency rescue means are available Yes No operating the equipment Yes No

    • The equipment is certified and up-to-date Yes No • WorkSafe has been notified (>5M) Yes No

    Work at height - emergency response plan


    In the event of an emergency, document or attach detailed description of how rescue is going to Work activity raw risk score:
    be performed, including the individual steps that will need to be undertaken: Refer to JSA
    Residual risk score:
    Refer to JSA
    Verified risk score: Verified
    on site by the permit receiver

    Permit issuer validation Permit receiver validation Permit Suspension (PS) and Permit Revalidation (PRv):
    The permit must be suspended at the end of each working
    I certify that I have reviewed the proposed work I certify that I am aware of the planned work day OR handover of shift; OR following an emergency;
    described on the Permit to Work documents and the controls detailed on this permit OR at the discretion of the PI and PR. The PTW MUST be
    and the JSA. and the JSA. I will ensure that work only revalidated prior to work recommencing.
    The Permit to Work is allowed: proceeds when the conditions set out are Date PS PR PI PRv PR PI
    met. I will ensure that others working under (✓) (initial) (initial) (✓) (initial) (initial)
    from: DD / MM / YYYY it understand and abide by the conditions.
    DD/MM
    until: DD / MM / YYYY DD/MM

    Name Name DD/MM

    DD/MM
    Signature DD/MM/YYYY Signature DD/MM/YYYY
    Date Date DD/MM

    Permit issuer Permit receiver


    I confirm this permit is now cancelled. I confirm that all equipment has been reinstated, isolations removed
    and the worksite is left in a safe and tidy state.

    Name Name

    Signature DD/MM/YYYY Signature DD/MM/YYYY


    V4-02-2020

    Date Date

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