DESCRIPTION OF LOCATION AND ACTIVITY
Permit requested for
(to be filled out by permit applicant)
Permit Applicant must tick yes to all of the following
A copy of Dive Cert. AS/NZS 2815 and valid medical is attached to this permit
Has a JHA/procedure or dive plan been prepared and is it available for the works?
Will diving flags be displayed?
The Dive vessel will monitor VHF CH16 and UHF CH14
Ships clearance to dive procedure has been activated, including shutdown and propeller immobilised if applicable – refer to ships shutdown procedures.
Is the person conducting the work suitably trained and competent?
Has the required PPE been identified and will it be worn by all persons involved?
Is all the dive equipment serviceable, fit for purpose and in current certification as per AS/NZS 2299.1 (2015)?
Is the Dive vessel is in survey (if applicable)?
Are people trained in First Aid available?
Permit Applicant to tick yes (Y), no (N) or not applicable NA to the following:
Will the diving work require jetty closure?
Has the wharf’s cathodic protection system been turned off?
Will the area be barricaded/cordoned off and warning signs displayed?
Will SCUBA equipment be used for the dive?
Will Surface Supplied Breathing Apparatus (SSBA) be used?
Will first aid equipment (including Oxygen) be carried?
APPLICANT STATEMENT OF ACKNOWLEDGEMENT
By signing this document, the Applicant:
- Agrees that they are responsible for the works being undertaken and that they and their contractors will work in a safe manner at all times; and
- Confirms that the company they represent and contractors will have:
- safe systems of work in place,
- will use equipment that is certified (as required) and fit for purpose,
- be competent in the type of work being undertaken, and
- hold all required permits and licences.
*There are errors on the form. Please check entered values.