General Work Permit

This permit is required for any non-routine or potentially hazardous maintenance work. Without limiting KPA’s discretion, examples include, high pressure water jetting, removal of handrails/gratings/fixed ladders, pressure testing (all situations), any work involving spraying of pesticides or insecticides, some works at the slipway (see HSE Slipway Guidelines) and launch and retrieval of vessels from the slipway. Note: As per KPA’s Permit to Work System some activities require specific permits (e.g. hot work, bunkering or diving). You must ensure you have the appropriate and required permit/s for your activity. *Mandatory fields.

Name

This field is for validation purposes and should be left unchanged.

APPLICANT DETAILS

Name of Permit Applicant
(person undertaking work onsite)

Name(Required)

Contact Number(Required)

Email(Required)

Company Name(Required)

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Company representative/contact filling out permit
(if different to permit applicant)

Name

Contact Number

Email

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DESCRIPTION OF LOCATION AND ACTIVITY

Vessel Name or Site Location(Required)

Description of Works(Required)

Equipment being used(Required)

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PERMIT DATES

Permit requested for
(to be filled out by permit applicant)

Start Date(Required)

DD slash MM slash YYYY

Start Time(Required)

Hours

:

Minutes

AM PM AM/PM

End Date(Required)

DD slash MM slash YYYY

End Time(Required)

Hours

:

Minutes

AM PM AM/PM

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PERMIT CONDITIONS

Permit Applicant to tick yes or no to the following

Will a pre-start discussion take place?(Required)

Yes

No

A JHA/Procedure/Lift Plan has been prepared and is available for the works?(Required)

Yes

No

Will work be occurring in areas where there are asbestos containing materials (ACM)? If yes, has this been included in the JHA and the KPA asbestos register must be signed.(Required)

Yes

No

Has the SDS for any chemicals being used been referred to in the JHA and is available for the works?(Required)

Yes

No

Will a spotter/sentry be nominated?(Required)

Yes

No

Will the area be barricaded/cordoned off and warning signs displayed?(Required)

Yes

No

Is the person/s conducting the work suitably trained and competent?(Required)

Yes

No

The required PPE has been identified and will be worn by all persons involved in the activity?(Required)

Yes

No

Is the equipment you are using fit for purpose?(Required)

Yes

No

For KPA Contractors and licence holders, has the relevant department (e.g. Maintenance/Engineering, Operations or HSE) been advised of the works?(Required)

Yes

No

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APPLICANT STATEMENT OF ACKNOWLEDGEMENT

By signing this document, the Applicant:

• Agrees that they are responsible for the works being undertaken and that they will work in a safe manner at all times and ensure that their contractors work in a safe manner;
• Confirms that the company they represent and contractors they use at the Port of Broome will:
  1. have safe systems of work in place;
  2. use equipment that is certified (when required) and fit for purpose;
  3. be competent in the type of work being undertaken; and
  4. hold all required permits and licences.

Name

Signature(Required)

Position

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Date

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Month

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Year

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