Whsmp · OPW16/0021

                                                                                             Isolation & Lock Out Permit
                                                                                                                        HB-HSEQ-F-074
                                                                                                                            Version: 4



                                                                                                       Permit No.
Section 1 – General Details
Subcontractor:
Project:
Work Activity Description:
Location of work:
Contractors name :
Section 2 – Assessment & Controls
Assessment                                                                                                           Yes       N/A
Safety requirements have been assessed and controls included in SWMS
The equipment meet relevant Australian Standards
The energy source can be safely and HAS been isolated
Any safety equipment that has to be used has been checked prior to use
Personnel conducting the work are trained, licensed and competent
Is there adequate fire protection for the work being conducted

Controls                                                                                                             Yes       N/A
A SWMS has been developed and is specific to and adequate for the work to be conducted
Controls in the work method statement are implemented, including (but not limited to):
 •   Lock outs and tags installed to isolate (valves, outlets, circuits etc.)
 •   Tests for dead (no pressure or electricity supply)
 •   Fire protection equipment installed (where required)
 •   Area barricaded and signed
 •   Working on live installations is NOT allowed
 •   Ladders and scaffolds are appropriate for the work, inspected and secure
 •   Persons who may be effected by the energy isolation have been notified (e.g. Hutchinson Builders
     employees or contractors)
 •   Non-essential personnel have been excluded from the area by either barricading or use of a dedicated
     spotter

Permit Request:
Type of Isolation:        Electrical           Plant         Equipment          Other
This acknowledgement signifies a formal request to commence the isolation permit. As the person requesting this permit, I hereby

certify as an …………………………………………………..… e.g.; (electrician – mechanical fitter – plumber) License No:…………………….……. that;
 •    I am competent to coordinate this isolation in accordance with the isolation Permit details
 •    I shall undertake to implement all planned and necessary controls to ensure safe isolation methods; and
 •    I shall monitor the isolation hazards and control methods throughout the isolation process.

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

Name:                                          Signature:                                    Date:                Time:
Section 3 – Implementation
Isolation Authorisation (Work Coordinator in Direct Control):
The procedures, control measures and precautions appropriate for the safe execution of isolation have been implemented and the
Hutchinson Builders permit issuer been advised of the completion of the electrical isolation Permit.

Name:                                          Signature:                                    Date:                Time:

Constraints:     This Authorisation is valid until the following occurs, or the date and time shown:
                                                                                             Date:                Time:
Completion of Permit – Hutchinson Builders Permit Issuer:
I declare that the permit is now closed and I have received a signed copy of the permit back from the competent person. The area
has been check and is free from any associated isolation risks.

Name:                                          Signature:                                    Date:                Time: