Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Scaffold Audit
General Information
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Permit #:
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Name of Scaffold Erector:
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Installation Date:
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Expiration Date:
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Renter's Name
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Phone #:
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Drawing on Site for Inspection?
Specific Information
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Scaffold Height:
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Number of Platforms Decked
Sidewalk Sheds Only
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Are there signs on the parapets?
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Are the lights working?
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Is the parapet the proper height and secured?
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Maintenance Information
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Are the base plates & mud sills secured?
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Are all the scaffold pins & bolts installed?
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Are the legs and poles plumb, braced and not displaced?
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Are cross braces fully attached, not bent, and not missing?
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Are tie-ins correctly spaced, properly secured & the correct amount?
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Are pipe clamps tight?
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Are window jacks tight?
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Are all the planks secured?
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Are decking and planks in good condition?
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Is deck fully planked?
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Are there any gaps or open spaces (> 1") on decking?
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Are the guardrails & toe boards secured at all places where required?
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Is the netting extension of full length and height?
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Is the netting secured?
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Is there proper access to the working platform of the scaffold?
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If access to the working platform is an extension ladder, is the ladder properly set up and secured?
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If access to the working platform is an extension ladder, does the ladder extend 3 feet past the landing point?
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Is the deck clean and free of debris?
Approval
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Signature:
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Date: