THE WORK PERMIT

St John Of God Burwood Hospital

• Work permit / Site access

• Site Location
  Address

• Work Order Number:

• Area of Work

  Hot Works

  Confined Space

  Working at heights

  Isolation Lock out/ Tag Out

  Excavation / Penetration

• Authorising Manager / Supervisor

  Dean Stamford

  Andrew Moar

  Other

• Add signature

  Sign

• Select date

  Date

• Access Authorised by

• Add signature

  Sign

• Select date

  Date

SITE ACCESS & WORK PERMIT ST JOHN OF GOD HOSPITAL BURWOOD

• ST JOHN OF GOD BURWOOD HOSPITAL CONTRACTOR INDUCTION

• Have You Already Completed and signed The ST JOHN OF GOD BURWOOD INDUCTION

  YES

  NO

Induction MUST Be Completed and signed Prior to Starting

WORK CLASSIFICATION

• Work Classification

  Select Plumbing Electrical Carpentry Painting Air Conditioning Service Audit Other

  • Plumbing
  • Electrical
  • Carpentry
  • Painting
  • Air Conditioning
  • Service
  • Audit
  • Other

• Classification

• Does The Work to Be Undertaken INCLUDE ANY Of The Following: <br>HOT WORK, CONFINED SPACE ENTRY, WORKING AT HEIGHTS, ISOLATION LOCK OUT / TAG OUT, EXCAVATION / PENETRATION

  NO

  YES

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Mobile Number

Attending Contractor Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• What Type of Work Is To Be Undertaken

  Select Hot Works Confined Space Working at heights Isolation Lock out/ Tag Out Excavation / Penetration

  • Hot Works
  • Confined Space
  • Working at heights
  • Isolation Lock out/ Tag Out
  • Excavation / Penetration

Hot Works

• Description of Work

• A Hot Works Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Confined Space

• Description of Work

• Confined Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Working At Heights

• Description of Work

• Working at Heights Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Isolation Lock out / Tag out

• Description of Work

• Isolation Lock out / Tag out Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Excavation / Penetration

• Description of Work

• An Excavation / Penetration Permit Must be attached to this form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Are all required forms / Permits attached

• Does The Work to Be Undertaken INCLUDE ANY Of The Following: <br>HOT WORK, CONFINED SPACE ENTRY, WORKING AT HEIGHTS, ISOLATION LOCK OUT / TAG OUT, EXCAVATION / PENETRATION

  NO

  YES

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• What Type of Work Is To Be Undertaken

  Select Hot Works Confined Space Working at heights Isolation Lock out/ Tag Out Excavation / Penetration

  • Hot Works
  • Confined Space
  • Working at heights
  • Isolation Lock out/ Tag Out
  • Excavation / Penetration

Hot Works

• Description of Work

• A Hot Works Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Confined Space

• Description of Work

• Confined Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Working At Heights

• Description of Work

• Working at Heights Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Isolation Lock out / Tag out

• Description of Work

• Isolation Lock out / Tag out Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Isolation Lock out / Tag out

• Description of Work

• Isolation Lock out / Tag out Permit Must be Completed and Details attached To This Form

• A Completed Job Specific SWSM Must Be Attached to this form

Excavation / Penetration

• Description of Work

• An Excavation / Penetration Permit Must be attached to this form

• A Completed Job Specific SWSM Must Be Attached to this form

• Are all required forms / Permits attached

• Work order Number:

• Contractor Company Name

• Contractor Company Supervisor Name

• Contractor Company Supervisor Contact Mobile Number

Technician Details

• Name

• Mobile Number

• Attending Technician/s Identification

  Media

• Description of work to be carried out

• Have Personnel Affected By Work Been Advised

  Yes

  No

  Uknown

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• I Agree Prior to Starting Work To Confirm With The Maintenance Supervisor That All Personnel Have Been Advised

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Have All Site Attendees Sighted the Asbestos Register

  YES

  NO

• Burwood Asbestos Register

  

• All Attendees HAVE Now Sighted the Asbestos Register

• Has SWMS / JSA been completed

  Yes

  No

  N/A

• Copy Of SWMS / JSA

  Media

• Permit Issued by

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Where is the SWMS / Related Documentaion

• Accepted

  YES

  NO

• Permit issued By

  Sign

• Position / Title

• Date Permit Issued

  Date

• Permit Valid From

  Date

• Permit valid To

  Date

• Permit Conditions
  1. Only an authorised Person may issue permits.
  2. Permit cannot be transferred to another person.
  3. This permit applies only to the work described.
  4. Person receiving permit must comply with permit conditions and instructions from Supervisor
  5. Permit is valid only for the time specified.
  6. Completed / Cancelled permits shall be retained on file for 7 years.
  7. Failure to observe permit conditions may lead to cessation of contract / disciplinary action.
  

• I have read this permit and understand the nature of work and the safety precautions to be taken.

  YES

  NO
Permit/s Issued to

• Name:

  Sign

• Date

  Date

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

• Permit Can not be issued

  Date

• Permit Denied By

  Sign

Completed Works Confirmation & Certification

• I Certify the work has been complete and made safe to resume normal activities

  YES

• Contractor Supervisor

  Sign

• Certified :

  Date