SECTION 1: Applicant Details |
Name of Permit Applicant
( person undertaking work onsite ) |
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Company representative/contact filling out permit
( if different to permit applicant ) |
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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 |
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SECTION 3: Permit Dates |
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SECTION 4: Permit Conditions |
Permit Applicant to tick yes, no or NA to the following: |
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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.
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Signature: |
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