Title Page

  • Permit to work number linked to this check list.

  • Working at heights Permit/List number - (auto generated)

  • Conducted on

  • Prepared by

  • Company

  • Location

  • undefined

  • Sub Location

JOB DETAILS

  • What works will be undertaken? Please give full details of the tasks involved.

  • Special Tools / Equipment to be Used (MEWP, Ladders, scaffold etc)

  • Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

Hazards - Fill in the relevant sections below.

  • Are you Qualified / Trained to undertake this work?

  • Have all personnel effected by the work been notified?

  • Has the working area been fenced or barricaded and warning signs in place?

  • Is there a risk of coming into contact with Overhead services such as Power Cables / Live Busbars etc?

  • Will the fire suppression system (sprinklers) need isolating?

  • Will the fire alarm/sensors need masking during the work?

Roof Access (Only required if roof access required)

  • Is a safe means of access to the roof provided?

  • Are Crawl boards with hand rails & roofing ladders to be used?

  • Is there a safe tested anchor point provided to secure workers using a Harness and Lanyard?

  • Have the Harness and Fall Arrest Lanyards to be used been inspected in the last 6 months?

  • Is the Fall Arrest Lanyard the correct length? (i.e. 3m shorter than the height of the structure)

  • Is Edge Protection required and fitted?

  • Is edge protection correct height? (Top Rail 1100mm Intermediate Rail 600mm 150mm Toe Board)

  • Have Fragile Surfaces been Protected? (i.e. Polycarbonate Skylights - Covered or Fenced off)

  • Has the weather forecast been checked?

  • Are the wind speeds being monitored using an anemometer? Max Speed 12.5m/s or 28mph gust.

  • Is the roof free of ice / frost?

  • Is lightning forecast?

  • Are there any ducts / vents / chimneys on the roof?

  • Is there a risk from fumes, dust or corrosion?

  • Is there a risk of encountering or disturbing asbestos?

  • Asbestos permit completed and other precautions in place to include additional PPE

  • Is there a rescue plan for getting an injured or ill worker down from the roof?

MEWP (Scissor Lift / Boom Lift)

  • Do you hold a current IPAF 3a / 3b Powered Access Licence? Please use media tag to add photographic evidence of licence.

  • Have you checked the work area including access ways for fragile surfaces i.e. drain lids/ manhole covers etc?

  • Have you checked wind speed using a handheld anemometer if working outside? Max Speed 12.5m/s or 28mph gust.

  • Have you got a Harness and Fixed Lanyard for operating a Boom Lift?

  • Have you checked for overhead hazards to avoid crushing injuries?

  • Is there a Standby Person on the ground trained to use the lowering controls in the event of a breakdown?

  • Have you got the Remote Control Tether to use the "Walking the Dog Method" when moving the platform in congested areas or through doorways?

  • Has the MEWP got a Valid LOLER Inspection Certificate?

Scaffolding (Fixed)

  • Has the scaffold been designed / erected and inspected by a competent person - and load rated for the works to be undertaken?

  • Is the scaffold tied to the structure using approved methods i.e. Hilti Fixings / Through Ties etc.

  • Has the scaffold got a Licence where required? i.e. Public Road / Pavement

  • Has the scaffold been fitted with a Scafftag Inspection System?

  • Has the Scafftag been completed in the last 7 days?

  • Is the Scaffolding protected from Vehicle Impacts at the base?

  • Is Debris Netting / Brick Guards required to stop items falling?

  • Are Rubbish Chutes required?

  • Are Ladders secured correctly / protected by self closing gates and have the required 3 rungs / 1m Take off area above the scaffold platform?

  • Is the scaffold protected at night, to prevent trespassers / unauthorised access?

Tower Scaffold

  • Do you hold a valid PASMA 3T competence card?

  • Has the tower been built correctly? Correct Height:Base Ratio / Use of Outriggers etc?

  • Is the work platform set up correctly - Top Guard Rail 1100mm high / Intermediate Guard Rail 600mm & Toe Boards 150mm high?

  • Have the Wheels been levelled and Locked?

FLT - Man-Riding Cage

  • Has the Cage been secured to the FLT using Clamps?

  • Has the Cage been secured using a back up method i.e. Chained the the Back Rest on the mast?

  • Has the FLT had a LOLER Check in the last 6 months (Used for lifting persons)?

  • Has the Man Riding Cage been LOLER Inspected in the Last 6 Months?

  • Has the Tilt Control in the FLT been locked out in accordance with the HSE Guidance issued in PM28 - Issue 4?

  • Having moving parts on the FLT been guarded so that the person working in the cage, doesn't make contact with moving parts?

  • Is there a method of communication between the Driver of the FLT and the worker in the Cage? i.e. 2 way radio.

  • Has the FLT Driver been trained in the use of FLT with the Cage mounted, and understands the safety rules. i.e. using handbrake / lock out of controls / remaining with the FLT at all times.

  • Has the Operative in the Cage got a Safety Harness and Fixed Lanyard (1.5 -2.0m) securely anchored to the designated floor anchor point in the platform.

  • Has the Harness and Lanyard been Thoroughly Inspected in the last 6 months?

Ladders / Stepladders

  • Is the ladder / stepladder being used for works of Short Duration (Max 30 mins in the same location) and Light Works (Max 25kg Tools / Equipment)

  • Is the ladder / stepladder the correct height for the works been undertaken? (Work not permitted from top 2 steps of a stepladder)

  • Is the Ladder / Stepladder Industrial Rated( i.e. SWL >150Kg)?

  • Is the Ladder / Stepladder in good condition? Is an Inspection Tag in place?

  • For Extension Ladders can the safe working Angle 75 Degrees (4:1 Ratio) be achieved?

  • Can the ladder be tied or secured at Top / Bottom?

  • Is the ladder suitable for the Environment - i.e. Fibreglass Non-conductive ladder for electrical works?

Other Precautions Required

  • Do you need to undertake any other precautions to undertake works safely?

  • Do you require any further safety / rescue equipment to undertake works safely?

I confirm that all necessary measures are in place to carry out the tasks safely and in accordance with the hazards identified on the permit.

  • Validity - Start time

  • Validity - Estimated completion time.

  • Permit acceptor

Hand Back and Cancellation of permit

  • I confirm that the work has been completed/partially completed, checked by myself and the area left in a safe and tidy condition.

  • Full Name and Signature of the acceptor and competent person/persons in Charge

  • Full name and signature of the permit issuer

  • Full Name and Signature of Duty manager. (If required)

  • Date and time of completion

undefined

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.