/ Form Number / APAOHS-01
Revision: / MAY 2013
Permit to Work / Issue Date:
Page: / 1 of 2
This document must be lodged with, and approved by, the Albany Port Authority before contractors can conduct non-routine work on site. Non-routine work performed by contractors must be planned so that hazards are identified and control measures put in place to protect personnel, plant and equipment and the environment. Please refer to the Contractors Handbook to clarify the meaning of Non Routine.
Non-routine work may include, but is not limited to: excavation, hot work, diving operations, construction, scaffolding, confined space work, abrasive blasting and any work under the berths.
Please contact the APA if you are unsure as to whether you need a permit.

Section 1: Application Details

Contractor’s Name / Position
Company Name / Date
Company Phone# / Mobile
APA Representative / Work Order

Section 2: Description of Scope of Work (include times and location)

Section 3: Checklist of Permits or Procedures to be completed

Please tick the appropriate boxes to show consideration of necessary procedures, refer to Contractors Handbook if unsure
Procedures / Yes / No
1 / Isolation & Tag Out Procedure?
2 / Job Safety Analysis (or equivalent) Completed?
3 / Port Inductions Completed?
4 / All staff have MSIC’s as required?
5 / Will Traffic Management be required?
Activity
1 / Confined Space – Contractor to provide detailed plan as per Australian Standard 2865-2009
2 / Excavation – see APA Excavation Permit
3 / Hot Work – See APA Hot Work Permit
4 / Working at Heights - APA Working At Heights Permit
5 / Crane Lift on or onto a berth, within16m of berth sheet piling, or EWP on a berth – APA Lift Permit (please contact APA to confirm requirements)
6 / Crane Lift – non berth related – no additional permit required
7 / Diving – See APA Dive Permit
8 / Abrasive Blasting – See APA Blasting Permit
9 / Working From a Vessel – See APA Working Afloat Permit
10 / Scaffolding – See APA Scaffolding Permit
11 / Vessel Fumigation – See APA Fumigation Permit

Section 4: Applicant’s/Contractor’s Regulatory Requirements

N/A / Yes / No
1 / High Risk Work licences – e.g. Forklift, EWP, Rigging, Crane, etc (Individual Operator)
2 / Heavy Vehicle Licences (Individual Operator)
3 / Classified Plant & Heavy Vehicle valid certificates/registration
4 / Valid Insurances – Public Liability & Workers Compensation
5 / MSDS – HAZCHEM
6 / PPE appropriate for Scope of Work (APA Mandatory PPE is a minimum)
7 / Marine Qualifications (Coxswain, Restricted Coxswain, Master Class 5 etc)
8 / Other (e.g. working at heights)

Section 5: Contractor Representative Statement of Acknowledgement

I acknowledge the requirements of the Albany Port Authority to identify and control risks and work in a safe manner at all times. I confirm the company has satisfactory documented safe systems of work in place and that all permits and licences required are in order and understood.
Company Representative Signature / Date & Time
Position in Company

Section 6: APA Representative Statement of Acknowledgement (APA Use Only)

I am satisfied that the contractor information provided to me is sufficient to show that the contractor has a system in place to fulfil their legal obligations to conduct works in a safe manner. This Permit to Work is approved subject to any conditions listed in Part 7 below.
APA Representative Signature / Date & Time
Position

Section 7. Specific Conditions / General Comments

Note: The applicant must hold a copy of this form at all times while on site.
T
The APA may withdraw this permit at any time if unsafe practices are observed.

Section 8: Notifications

Engineer / Maintenance
Safety / Environment
Security / Pilots

This copy printed:15/02/12 13:28