Scaffold Request Form

Job Detail

• Address
  Address

• Job ID

• Requested By

• Contact Number

Scaffold Application

• Description of Work

• Maximum number of Persons using scaffold

• Type of Access Required

  Tube and Fit

  Aluminum Tower

• Pavement/ Road Permit Required?

  Yes

  No

• Pulley/ Gin Wheel Required?

  Yes

  No

• Number of Working Lifts

• Please provide annotated pictures of each elevation where scaffold is required

  Media

• Approximate Height (metres)

• Approximate Length (Metres)

• Proximity Hazards/ Considerations

• Other Considerations

• Name and Signature of Requester

  Sign