Kimberley Ports Authority - Hot Work Permit

SECTION 1: Applicant Details

Name of Permit Applicant
( person undertaking work onsite )

Name:

Contact No:

Company:

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

Name:

Contact No:

Email:

_{Note: The vessel will apply for a hot work permit if hot work is being undertaken by the ship’s crew and on the vessel. If a contractor is undertaking the hot work on the vessel then the contractor will apply for the hot work permit.}

SECTION 2: Description of Location and Activity

Vessel Name or Site Location:

Description of Works :

Equipment being used :

SECTION 3: Permit Dates

Permit Requested From:

TO

SECTION 4: Permit Conditions

Permit Applicant to tick yes, no or NA to the following:

Has/will a pre-start discussion take place?:

YesNoN/A

Has/will a JHA been prepared and identifies PPE, Barricading/signage,ventilation/wind direction, cooling down of area after completion and inspections to be carried out after 30 mins?:

YesNoN/A

Has/will the area where hot work is occurring been assessed for potential hazards, and cleared of any combustible materials that may catch fire during the hot work operations?:

YesNoN/A

Has/will all Machinery / Equipment been isolated and Tagged Out as necessary?:

YesNoN/A

Has the person(s) operating the hot work equipment been deemed competent?:

YesNoN/A

The following equipment is to be on standby at all times; fire extinguisher, fireblanket, water supply (buckets of water or water hose) and communication (mobile or radio) :

YesNoN/A

Is the area in which hot work is to be conducted in close proximity to flammable liquid, explosive or hazchem storage facilities? If yes – special precautions may apply, Permit Authoriser to refer to the appropriate KPA Manager:

YesNoN/A

Is the Hot work to be conducted in a confined space? (if yes a confined space permit to be completed):

YesNoN/A

Confirm the above has been reviewed and Work pack will be completed for KPAemployees and KPA contractors by Works coordinator or delegate:

YesNoN/A

SECTION 5: 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:

have safe systems of work in place;
use equipment that is certified (when required) and fit for purpose;
be competent in the type of work being undertaken; and
hold all required permits and licences.

Signature:

Use your mouse or finger to draw your signature above.

Position:

Name:

Date: