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.

APPLICANT DETAILS

Name of Permit Applicant
(person undertaking work onsite)


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


DESCRIPTION OF LOCATION AND ACTIVITY


PERMIT DATES

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

:
:

PERMIT CONDITIONS

Permit Applicant to tick yes or no to the following

Will a pre-start discussion take place?*
A JHA/Procedure has been prepared and is available for the works?*
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.*
Has the SDS for any chemicals being used been referred to in the JHA and is available for the works?
Will a spotter/sentry be nominated?*
Will the area be barricaded/cordoned off and warning signs displayed?*
Is the person/s conducting the work suitably trained and competent?*
The required PPE has been identified and will be worn by all persons involved in the activity?*
Is the equipment you are using fit for purpose?*
For KPA Contractors and licence holders, has the relevant department (e.g. Maintenance/Engineering, Operations or HSE) been advised of the works?*

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.
 
*There are errors on the form. Please check entered values.