Whsmp · OPW16/0021

                                                                                                               Working at Heights Permit
                                                                                                                                                 HB-HSEQ-F-077
                                                                                                                                                     Version: 6


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 8 – 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 3 of 3