Whsmp · OPW16/0021

                                                                                                                  Working at Heights Permit
                                                                                                                                                       HB-HSEQ-F-077
                                                                                                                                                           Version: 5


Are guardrails
Section   5 –and
          6      toe boardsoff
               Working      in place on all open
                                 Trestles
                                 portable    and sides
                                              step     of the
                                                   Planks
                                                     and      scaffold ladders
                                                            platform
The   work area will require specific cleaning to ensure ground conditions are stable
Requirement                                                                                                        If No, Additional Control measures must be put in place
(e.g.; firm, level & safe) Ensure mobile scaffold is not located closer than 2 meter to any            Yes   No    or work activities must be terminated
slab  edge, penetration
Are trestles     and planks or    other condition
                              in good   step down,and
                                                    unless a fixed
                                                      are free     fence,
                                                                from      railororbroken
                                                                     cracks        suitablyparts
                                                                                            high–
Is the ladder
upturn    islock   in good condition and treads secure and not cracked or broken
              in place.
braces,           pins etc
Has ayou
Planks
Will    work
         are    method
             beonly
                 conductingstatement
                      to span  light
                               to take been
                                     works   developed
                                       the when
                                           applied load for
                                                  working   the
                                                        – off   work
                                                          provide
                                                              the     activity
                                                                  ladder?
                                                                   diagram If of
                                                                              Nosetreturn
                                                                                     up distances
                                                                                          to section
between
3  or 4 on trestles
              this permit.
                        required for intended weight
Will you be able to have and maintain three points of contact at all times working off                             If No a Platform ladder must be used
Where a ladder access is to be provided it shall be 900mm above platform height
the ladder?
Is the base of the ladder
                   trestlesmounted
                            mountedon
                                    ongood
                                       goodand
                                            andstable
                                                stableground
                                                       ground
                                                                                                                   If Yes
                                                                                                                      yes an
                                                                                                                          return
                                                                                                                             internal
                                                                                                                                  to section
                                                                                                                                      and external
                                                                                                                                              3 or 4 on
                                                                                                                                                     hand
                                                                                                                                                        thisrails
                                                                                                                                                              permit.
                                                                                                                                                                  are to
Will your job task require you to work above 2 meters
                                                                                                                   be fitted
If required
Has  fall hazards
             to usebeen
                    as aaccess
                        n access
                               fortoworking
                                     a work under
                                            platform
                                                  2 meters
                                                      – to be–extended
                                                              keeping area
                                                                         900mm
                                                                            clearabove
                                                                                  of objects                       If No install a hand rails system on trestles
by 1.5 meters from trestles
landing
Can awork
Has    workbemethod
               completed  without
                      statement     overdeveloped
                                 been    reaching and  or standing
                                                   for the         or kneeling on the top
                                                           work activity                                           If No return to section 3 or 4 on this permit
step of platform
Has a work method statement been developed for the work activity

Permit Request:
This acknowledgement signifies a formal request to commence Working at Heights. As the person requesting this permit, I hereby certify that the risk of falls
have been considered as per the hierarchy for controls:
  I am competent to coordinate Working at Heights in accordance with the Working at Heights Permit details;
  I shall undertake to implement all planned and necessary controls to ensure safe Working at Heights methods; and
  I shall monitor Working at Heights hazards and control methods throughout the Work at Heights.

Name:                                                       Signature:                                            Date:                          Time:
Hutchinson Builders Authorisation:
This Hutchinson Builders Authorisation signifies that the planning component of the Working at Heights Permit has been completed and that the Work at
Heights is authorised to commence in accordance with the Permit Request.

Name:                                                       Signature:                                            Date:                          Time:
Section 7 – Implementation
Working at Heights Authorisation (Work Coordinator in Direct Control):
The procedures, control measures and precautions appropriate for the safe execution of Working at Heights has been implemented and the persons
required to work have been advised of and understand of the requirements of the Work at Heights Permit.

Name:                                                       Signature:                                            Date:                          Time:

Constraints:           This Authorisation is valid until the following occurs, or the date and time shown:

                                                                                                                  Date:                          Time:




                                                                                                                                               Page 2 of 294