Cold Work Permit Form –
DCW / DBLB
The Applicant shall complete sections 1 and 2, sign section 3 and submit to the PPA Wharf Manager for approval.The Permit Checklist has been reviewed with the applicant prior to the commencement of work.
PPA Use / Permit No.: / EDOC No.:
SECTION 1: General
Applicant Company:
Phone: / Fax:
Company performing works: / Phone:
Company representative in charge of works:
Person in attendance: / Phone:
Permit Valid From: / (Hrs) / Date: / To: / (Hrs) / Date:
SECTION 2: Work Details, Precautions & Conditions
2.1 Description Of Work
DCW / DBLB
Location of Work:
(Specific)
Description of Work:
(type/personnel/equip)
2.2 Permit Checklist
Does the work involve: / Y / N / If yes obtain:
1. Excavation, cutting, drilling, penetrating ground by more than 100mm, or drilling into walls? / Dig Permit
2. Work with potential to generate heat or spark, (e.g. welding, cutting, grinding, abrasive blasting etc) result in fire associated with equipment, vessels, or structures in vicinity incl fire associated with other operations eg bunkering? / Hot Work Permit
DCW / DBLB / General
3. Abrasive blasting? / Abrasive Blasting Checklist
4. Any space not designed for normal work, where rescue may be difficult eg roof spaces, underneath buildings, within tanks? / Confined Space Permit
5. High Voltage (HV) incl entry to any signed HV space or cabinet. 240V electricity which cannot be isolated. Sewer or sewage systems, gas or high pressure water? / Services Permit
6. Height greater than 2.4m involving risk of an unrestrained fall or any work at a height of less than 2.4m involving risk of a fall from one level to another? / Working at Heights Permit
7. Work within 3 m of road within Port and KBIE requiring decreased speed limits or use of safety barriers or has the potential to impact traffic flow? / Traffic Permit
8. All lifts over 20t on DCW or more than 1.5t / m2 on DBLB? / Heavy Lift Permit
9. Handling dangerous goods (DG) incl DG transported onto or off PPA land, transported onto DCW or DBLB, loaded onto or off vessels, or in transit on vessels in Port? / Dangerous Goods Permit
10. Removal of native vegetation, work in or near a previously undisturbed area or within a National Heritage Listed area? / Environment and Heritage Permit
11. Diving within 200m of PPA wharf facilities - DBLB, DCW, ALF, HLO, Barge Ramp? / Diving Permit
12. Loads greater than 4.3m high, 2.4m wide, 19m long or over 42.5t? / Oversized Load Permit
2.3 Permit Conditions
Y / N / N/A
1. Fire Extinguisher is to be on standby at all times.
2. If required, a fire watch has been organised, fire equipment laid out ready for use, or the fire pump or fire brigade is on standby.
3. JHA / JSA / JSEA / WMS / SWI has been prepared for the works, if not, provide explanation:
4. Combustible materials have been removed from the work area or made safe.
5. Barricades and warning signage are to be in place at all times.
6. Equipment is isolated electrically.
7. Hoses, electrical leads and equipment have been tested/tagged in accordance with Australian Standards.
8. Applicant is aware of location of:
§ Ammonia pipeline and equipment;
§ bunkering points, fuel lines, fuel shut off points;
§ fire hoses, mains and water outlets;
§ fire alarms; and
§ UHF radio communications to Port Communications.
9. No Payment will be made for delay costs unless wharf manager signs off day works sheets on the day delayed.
10. The Company representative in charge of works / person in attendance agrees to advise all team members of Permit Conditions.
11. Other special conditions/ precautions:
2.4 Required Permit Documentation
Y / N / N/A
1. JHA / JSA / JSEA / WMS / SWI has been prepared for the works, if not, provide explanation:
SECTION 3: PPA Receipt, Permit Approval & Permit Acceptance
If the Applicant is the Company which will carry out the work, by applying for this permit it makes the following warranties, undertakings and acknowledgements:
1. The Applicant warrants that it understands the nature of the work permitted by the permit and risks associated with it, has sufficient competence to carry out the work andaccepts responsibility (including occupational health and safetyresponsibility)for the work.
2. The Applicant undertakes to notify PPA as soon as possible afterit identifies any issue which would prevent the work from being carried out safely, and to liaise with PPA to allow the work to be carried out safely.
3. The Applicant acknowledges that the issuing of this permit does not constitute approval by the PPA of the work or occupational health and safety procedures in relation to the carrying out of the work.
4. The Applicant warrants that, where it has particular expertise or technical knowledge with respect to the work permitted by the permit, it accepts that it, and not PPA, exercises control over that work and is responsible for any occupational health and safety obligations arising from that work.
If the Applicant is not the Company which will carry out the work, by applying for this permit it makes the following warranties, undertakings and acknowledgements:
1. The Applicant warrants that it understands the nature of the work and risks associated with it.
2. The Applicant undertakes to take whatever steps are required to ensure that the Company which will carry out the work understands the nature of the work and risks associated with it.
3. The Applicant warrants that the Company which will carry out the work has sufficient competence to carry out the work andaccepts responsibility (including occupational health and safetyresponsibilityfor the work.
4. The Applicant undertakes to take whatever steps are required to ensure the Company which will carry out the work notifies the PPA as soon as possible afterit identifies any issue which would prevent the work from being carried out safely and liaises with the PPA to allow the work to be carried out safely.
5. The Applicant undertakes to take whatever steps are required to ensure the Company which will carry out the work understands that the issuing of this permit does not constitute approval by the PPA of the work or occupational health and safety procedures in relation to the carrying out of the work.
Applicant’s Authorised Representative:
(Name) / (Signature) / (Date)
(Title)
Permit Authoriser:
(Name) / (Signature) / (Date)
Notifications: / Wharf Manager / Y N / Environment / Y N / Safety / Y N / Other:
Maintenance / Y N / Engineering / Y N / Security / Y N
SECTION 4: Completion
The work has been completed and all persons who had a role in carrying out the work, materials and equipment have been withdrawn.
Authorised Representative of Applicant Signed / OR / Company in Charge of Works Signed
(Name) / (Signature) / (Date)
Permit Authoriser:
(Signature) / (Date)
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