HV Electrical Access/Isolation Permit

Permit ID *

All staff and contractors must use this form to gain authorisation prior to performing any works on or near HV electrical equipment or HV cables on ADG premises. This Permit is issued only for the occasion specified below. A signed copy of this Permit must remain on site during the works.

Status

Are you or your business registered with ADG? *

YesNo

Note: registration is necessary before any work on ADG Leased Area is permitted.

*Please register your business with ADG before proceeding. Please click here to register.

Have you read the Working on Airport induction? *

YesNo

*Please complete the Working on Airport induction before proceeding with the application.

Part 1 – Application Details

Please select the type of permit you want to apply *

Access onlyAccess and Isolation

Company *

Person in Charge of Works *

Phone number *

NT Electrical Licence No. *

Email *

Part 2 – Description of Works

Location of Works *

Describe the planned works *

Sketch the planned works or upload a photo of the sketch:

Clear drawing

Please upload a photo of sketch if not drawn above

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ADG Project Manager Email *

Other PM Email *

Part 3 – Conditions of Isolation

The following precautions have been taken:

Isolation points *

Has your Switching Permit been approved? *

YesNoNot Applicable

Please comment *

Please attach the switching permit *

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HV conductors have been earthed at the following points: *

Nearest live points Note: The Conditions of Isolation from points of supply must remain unchanged during the currency of this Permit.

Part 4 – Acknowledgement of Electrical Worker in Charge of Works

I understand that it is my responsibility to ensure that all persons working under this Permit have read the above conditions and signed the Work Party Sign-On and Off each time before commencing works and again on leaving the site. *

Name of Electrical Worker in Charge of Works *

Signature *

Draw signature|Type signatureClear

Date

Please select an available ADG authorised person *

Part 5 – Authorisation to Work

Is the permit approved? *

YesNoMore Information Required

Reason for disapproval/ Notes to the applicant *

I authorise the above work to proceed as listed in this form. *

Name and Title of ADG Authorised Person *

Phone Number *

Authorised Person's Signature *

Draw signature|Type signatureClear

Date and Time

Part 6 – Commencement of Works

Name of All Recipients (Person in Charge)	Sign On (Date and Time)	Sign Off (Date and Time)

Part 7 - Work Party Sign On and Off

Worker's Name	Sign On (Date and Time)	Sign Off (Date and Time)

Please select an available ADG authorised person *

Part 8 – Cancellation of Permit and Completion of Works

Cancellation Date and Time *

As-built drawings or amendments are: *

Not requiredRequired

As-built drawings or amendments will be provided by *Responsible Person

Provided by date *For providing As-built or amendments drawings

Please upload a photo of the completed Part 6 and Part 7 of the permit *

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(Photo of the Commencement of Works and Work Party Sign on and off section)

Please upload a photo of the site

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I confirm that: *

The works described in this Permit have been satisfactorily completed or stopped and made safe.All persons under my control have been withdrawn.Any outstanding matters have been forwarded to the ADG Authorised Person for action.This Permit is now cancelled.

Recipient Name *

Recipient Signature *

Draw signature|Type signatureClear

Recipient Signature Date

Part 9 - Cancellation of Permit from the ADG Authorised Person

Name of ADG Authorised Person *

Date *

Signature *

Draw signature|Type signatureClear

CAPTCHA *

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