Vine Property Management - General Permit to Work Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Instructions: DO NOT USE THIS FORM FOR CONFINED SPACE ENTRY. A specific Confined Space Entry Permit is required.
  
  1. Review the Property Hazard Awareness Chart for the applicable site – if there are high-risk hazards present, this Permit to Work is required to be completed and issued to the contractor.
  
  2. Forward this General Permit to Work Form to the contractor along with the Work Order and request a signed copy to be returned to ensure payment of services is not delayed.
  
  3. On receipt of the Permit following completion of the work, ensure the Permit is closed out and retained on file for the site.

WORK ORDER NO:

WORK LOCATION (Site Details):

• Add location
  Address

DESCRIPTION OF WORK TO BE COMPLETED:

• Permit Issued to:

• Organisation:

• On-site Contact No: (Mobile/ extension)

PERMIT TYPE – Type of High Risk Task to be performed (tick below):

• Electrical Isolation - Relevant SWMS must be submitted before works commence

• Gas Isolation - Relevant SWMS required before works commence

• Fire Isolation - Required to complete a Fire Services Impairment

• Plant & Equipment Isolation - Relevant SWMS required before works commence

• Hazardous Materials - Relevant SWMS & MSDS required before works commence

• Hot Work - Required to complete a Hot Works permit

• Working at Heights - Relevant SWMS required before works commence

• Access to Roof - Required to complete Roof Access form

• Other

• (Please state) ………………………….

PERMIT DURATION:

• This permit is valid from:

  Date

• To:

  Date

SAFETY REQUIREMENTS -

• List additional hazards and specific risk control measures as identified on the Property Hazard Awareness Chart:

CONTRACTOR AGREEMENT

• I agree that all work will be carried out in accordance with the conditions of this permit. Where additional hazards are present (as indicated above), a documented Risk Assessment/Safe Work Method Statement has been developed to identify the risks and associated control measures prior to commencement of work. NOTE: In order to ensure prompt payment, a copy of the new/amended SWMS is to be forwarded with this Permit to Colliers on completion of the work.

• Name:

  Sign

• Position:

• Select date

  Date

Vine Property Management - APPROVAL

• The Contractor named in this Permit is authorised to conduct the stated works providing the requirements of this Permit have been met.

• Permit expires on:

  Date

• Authorised (print name):

  Sign

• Date:

  Date

• This permit must be returned to:

Vine Property Management - PERMIT CLOSE OUT

• NOTE: The Contractors revised SWMS has been submitted and identifies additional hazards and required risk control measures as specified on this Permit.

• Authorised Representative (print name):

• Permit returned:

  Date

PERMIT CONDITIONS

•  This permit applies only to the work described
   Permit is valid only between hours specified
   Failure to observe permit conditions may lead to disciplinary action
   Permit cannot be transferred to another person
   Person receiving permit must comply with all Colliers’ Procedures and site-specific requirements