To Be Completed by the Person / Company Who Is Requesting / Requiring the Isolation

/ FIRE INDICATOR PANEL ISOLATION AND DE-ISOLATION PERMIT / Issue Date:01/07/16
ReviewDate:01/07/18

·  To be completed by the person / company who is requesting / requiring the isolation

·  A risk assessment must be undertaken and attached to this permit along with a SWMS

·  A copy of this permit must be attached to the FIP

·  The permit and risk assessment will be reviewed by an GPNSW Authorised Officer

·  The authorised officer of Property is responsible for completing the Fire Protection Impairment Notification and sending this to the insurer as required through the Treasury Management Fund – fire impairment notification process.

·  Responsibility for the safety controls listed in the risk assessment remain with the person requesting the isolation

1. Person requesting the isolation / Permit Number
(Building-FIPP-date)
Name of person requesting the isolation / ¨ Tenant
¨ Business Entity
¨ Contractor / (name)
Signature / Date of submission
Phone number
2. Isolation request details: complete and forward to Property
Building / Level/s / Room/s
Reason for isolation / ¨ Maintenance
¨ Construction
Requirements (areas marked with* will require insurance company notification / Isolate at the building
(for areas/levels only) / ¨ Yes. ¨ No / Isolation occurring under the following conditions
Less than 12 hours only, during business hours 6am-1800, less than 20% of building isolated
(ie: daily) / ¨ Yes. ¨ No*
Isolate from security office
(for more than 20% of the building) / ¨ Yes.* ¨ No / Isolate for more than 12 hours or overnight
(ie: continuous) / ¨ Yes.* ¨ No
Isolation date / De-isolation date
Isolation time / De-isolation time
Indicate days / ¨ Mon. ¨ Tues. ¨ Wed. ¨ Thurs. ¨ Fri. ¨ Sat. ¨ Sun.
3. Authorisation (Facilities Use): / * For isolation: Tresury Managed Fund must be notified under the following conditions >20% building isolated, after hours, more than one day through the Treasury Management Fund – fire impairment notification process.
Name of person authorising the isolation / Use link to the notification form
Certificate number & expiry
Signature / Date of authorisation
Phone number
4. Implementation
Name of person isolating the FIP / Phone Number
Date of isolation
Signature / Time isolated
Name of person
de-isolating the FIP / Phone Number
Date of de-isolation
Signature / Time de-isolated
Custodian: WHS Manager / Uncontrolled copy when printed / ©GPNSW
Approved by: Place Management / Version: 1.0
Number: SMS-02-FM-A1175697 / Page 1 of 1