Work Permit - Working at Height

• Site conducted

  Select
• Location
  Address

Validity Period

• Issued By:

• Issued To: (Full Name)

• Issued to (Company Name)

• Valid from: (Date & Time)

  Date

• To: (Date & Time)

  Date

Work Description

• Equipment or area to which Permit applies:

• Description of Work to be Carried Out:

• Description of Specific Hazards (e.g. Falls from Height or Falling Objects)

• Access Equipment:

  Select Tower Scaffold Scaffold Cheery Picker Ladder or Stepladder Other

  • Tower Scaffold
  • Scaffold
  • Cheery Picker
  • Ladder or Stepladder
  • Other

• Comments:

• Precautions:

  Select Anchor Points Harness & Lanyard Safety Rails Area Cordon off (under work) Method Statement Risk Assessment Safe System of Work Other

  • Anchor Points
  • Harness & Lanyard
  • Safety Rails
  • Area Cordon off (under work)
  • Method Statement
  • Risk Assessment
  • Safe System of Work
  • Other

• Comments:

• Additional Permits Required:

  Select Hot Works Electrical Confined Spaces Not Applicable Other General

  • Hot Works
  • Electrical
  • Confined Spaces
  • Not Applicable
  • Other
  • General

• Comments:

Sign Off

• By clicking this box I hereby confirm that I have read, understood and will abide by the ACE Express Site Rules at all times whilst working on site.

• Ace Staff Signature

  Sign

• Contractor Signature

  Sign