LV Electrical Access/Isolation Permit

Permit ID

All contractors must use this form to gain authorisation prior to performing any LV electrical works on ADG premises.

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 Requirements? *

YesNo

*Please click here to read the requirements. Once completed, please select "Yes" to proceed.

Part 1 – Application Details

Company *

Person in Charge of Works *

Phone number *

NT Electrical Licence No *

Email *Applicant's email address.

Do you have an ADG Project Manager for this task? *

YesNo

ADG Project Manager Email *

Other PM Email *

Part 2 – Works Details

Description of Works

Location of Works *

Building Owner *

Describe the planned works *

Do you have sketch or drawing to attach?

YesNo

Please attach sketch or drawing *

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Equipment

Equipment Identifier *(e.g. Distribution Board Number, Asset Number)

Circuit Number *

Date Isolated *

Date Re-Energised *

Notifications

ADG staff Notified? *

YesNo

ADG Staff - People Notified *

ADG Staff - Date and Time Notified *

ADG Tenants Notified? *

Yes No

ADG Tenants - People Notified *

ADG Tenants - Date and Time Notified *

Checklist

Will you be performing live work? *

YesNo

* Electrical work on energised electrical equipment is prohibited under Regulation 154 unless an exemption applies. If you intend to perform live work, you must include a documented risk assessment, approved by the ADG authorised person.

Please attach a documented risk assessment. *

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Have you provided a documented risk assessment that has been agreed to by an ADG Authorised Person? *

YesNo

Please comment *

Do you have a lockout kit? *

YesNo

Please comment *

Do you have an LV rescue kit and trained spotter for this work? *

YesNo

Please comment *

Have you reviewed the ADG drawings? *

YesNo

Please comment

Part 3 – Acknowledgement of Electrical Worker in Charge of Works

I confirm that:

I understand the hazard of this work and the precautions to be taken.
I will comply with the ADG special conditions decided by the ADG Authorised Person.
I have discussed the hazards and precautions I will take with the ADG Authorised Person.
I will return my copy of this Permit for cancellation by the ADG Authorised Person, once work has been safely completed.

Name of Electrical Worker in Charge of Works *

Signature *

Draw signature|Type signatureClear

Date

Please select an available ADG authorised person *

Part 4 – Authorisation to Work

Is the permit approved? *

YesNoMore Information Required

Reason for disapproval/ Notes to the applicant *

ADG Special Conditions

Please upload relevant documents (if any)

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I authorise the works listed above to proceed during the specified dates and times, in accordance with the ADG special conditions noted in Part 2 above: *

Name and Title of ADG Authorised Person *

Phone Number *

Authorised Person's Signature *

Draw signature|Type signatureClear

Date and Time

Please select an available ADG authorised person *

Part 5 – Completion of Works

Locks have been removed *

YesNo

Reason if "No" *

‘Danger’ tags have been removed *

Yes No

Reason if "No" *

Circuits have been re-energised *

YesNo

Reason if "No" *

Legends have been updated *

YesNo

Reason if "No" *

Do you have a Certificate of Compliance (CoC)?

YesNo

Reason if "No" *

Please attach the Certificate of Compliance (CoC) *

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Part 6 – Cancellation of Permit from Person in Charge

I, the Electrical Worker in Charge of Works, confirm that: *

The works described in this Permit have been satisfactorily completed or stopped and made safe.

All people under my control have been removed from the site. *

Any outstanding matters have been forwarded to the ADG Authorised Person for action. *

This Permit is now cancelled. *

Please attach a photo of the site

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Name of Electrical Worker in Charge of Works *

Signature *

Draw signature|Type signatureClear

Electrical Worker in Charge of Works Signature Date

Part 7 - Cancellation of Permit from the ADG Authorised Person

I, the ADG Authorised Person, confirm that: *

This Permit is now cancelled.

The works described in this Permit have been inspected by me. *

YesNo

Name of ADG Authorised Person *

Signature *

Draw signature|Type signatureClear

Date *

CAPTCHA *

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