Fire system Permit

• Site conducted

  Select

• Permit No.:

• Associated PTW Number:

• Associated Permits:

• Work specified in the Permit is conditional on all contractors having read, understood and signed the Health & Safety policy.

• Requested By:

• Date of Notification:

  Date

Who:

• Name of company:

• Competent person in charge:

• Other personnel engaged in the works:

When:

• Impaired From:

  Date

• Restoration Anticipated:

  Date

Where:

• Occupancy involved:

What:

• Description of work:

• Comments / Special conditions:

• Management notified?

  Yes

  No

  N/A

• Fire brigade notified?

  Yes

  No

  N/A

• Patrol rounds arranged?

  Yes

  No

  N/A

• Emergency water supply available?

  Yes

  No

  N/A

• Hazardous operations prohibited?

  Yes

  No

  N/A

• Hot work suspended?

  Yes

  No

  N/A

• 24 hours occupancy?

  Yes

  No

  N/A

• Smoking prohibited?

  Yes

  No

  N/A

• Additional equipment?

  Yes

  No

  N/A

• Other - specify

  Yes

  No

  N/A

• Specify:

• Impairment – the red impairment tags “Out of service” should be attached to impaired equipment

• Restoration – the red impairment tags should be removed

• Approved by:

• Date:

  Date

• Signature:

  Sign

Authorisation:

• Authorisation: I hereby declare that the above safety precautions are in place and the Fire system has been impaired.

Issued:

• Issued By:

• Date:

  Date

• Signature:

  Sign

Closure:

• Closure: I hereby declare that the Fire system has been restored to full operation and this Permit closed.

• Closed by:

• Date:

  Date

• Signature:

  Sign