ROOF ACCESS PERMIT

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

PERMIT DETAILS

• Property Address

• Work Request Number

• Date of Permit

• Time of Permit -Permit Begins_ -Permit Ends_

• Contractor Company Name

• Contractor Representative Name

• Contact Number

• Description of work to be undertaken

• Location of work

• Potential hazard(s) (Consider attributes of roof e.g. gradient ≥15° construction materials - age, condition; slip/trip, fall, Legionella, radiation hazards etc.)

• SWMS or Risk Assessment provided?

  Yes

  No

  N/A

• Does the task have any need to exit the fixed walkways?

  Yes

  No

  N/A

• Is fall restraint equipment being used for this work? If YES, has an appropriate RESCUE PLAN been provided?<br>

  Yes

  No

  N/A

ROOF ACCESS REQUIREMENTS (To be completed by person requiring access to roof)

• List persons requiring access to the roof:

Steep Roof (i.e. ≥15°)

• If the roof gradient is steeper than 15° will workers be attached at all times to an anchor point*?

  Yes

  No

  N/A

• If yes, confirm the anchor point has been tested, <br>inspected and certified

  Yes

  No

  N/A

Unprotected Edges

• Is work within 2m of an unprotected roof edge or roof penetration (e.g. skylight)?

  Yes

  No

  N/A

• If YES, Answer all questions in this section<br>If NO, go to ‘Weather Factors’ section

  Yes

  No

  N/A

• Is a Fall Protection System available that includes a safety harness and attachment lanyard that has been suitably installed and maintained, or will the contractor supply and use a roofer’s kit or temporary anchor system?

  Yes

  No

  N/A

• Are temporary guardrails required to be erected?

  Yes

  No

  N/A

• Is temporary safety netting / mesh required to be provided?

  Yes

  No

  N/A

• Is any additional action required to make access safe (e.g. a walkway or crawling board)?If Yes please specify:

  Yes

  No

  N/A

Weather Factors

• Are the weather conditions such that the work can be carried out safely? (Consider wind, precipitation, lightening etc.)

  Yes

  No

  N/A

• Will equipment and consumables be secured (and later removed), as appropriate, to prevent them falling from height or blowing off the building?

  Yes

  No

  N/A

Other Hazards

• Are there Radio Frequency Radiation Emitting Devices on the roof or nearby?

  Yes

  No

  N/A

• If YES, has the hazards been identified and relevant risk controls implemented?

  Yes

  No

  N/A

• Are there any additional hazards that may pose a risk to safety?

  Yes

  No

  N/A

• If YES, list the hazards and associated risk controls to be implemented:

• Has a rescue plan been put in place for work that requires the use of fall protection systems?

Sign Off

• Permit Approved:

• Date and Time

  Date

• By

  Yes

  No

  N/A

• Permit Completion

• Date and Time

  Date

• Contractor

• Physical work area returned to safe condition

• Permit Conditions:
  1. This permit applies only to the work described
  2. Permit is valid only between the hours specified
  3. Permit must be displayed at location of works
  4. Failure to observe permit conditions may lead to cessation of work/ contract
  5. Permit cannot be transferred to another person
  6. Person receiving permit must comply with instructions of relevant Dealership Manager / Supervisor / Job Captain
  7. Only Authorised Person can issue a permit.
  8. Authorised Person must assess hazards and list precautions to be taken.