Restricted Items Use Permit

Permit ID

Airport Development Group (ADG) encourages workers and contractors to use alternative tools where possible . If not possible to use an alternative tool, a task specific risk assessment must be provided and the Approved Restricted Items Use Permit must be submitted and approved prior to commence any work.

Restricted tools must be used by an experienced and competent person only.

ADG Restricted Items:

A-Frame Ladder (excludes Platform Ladders)
Extension Ladder
Cut Off/Concrete/Demo Saw (including when used in trolley)
Nine Inch Grinder
Explosive Power Tools

Status

Application Date *

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

Select Airport *

Assessor *

Business Name *

Applicant Name *Person in Charge of Works

Phone *

Applicant Email *

ADG Point of Contact/ Project Manager Details

ADG Point of Contact Name *

ADG Contact Email *

Part 2 – Description of Works

Address of Works *

Start Date of Works *

End Date of Works *

*End date must be after the start date of works.

Hours of Work (From) *

Hours of Work (To) *

Checklist *

Inspected, serviced and in good working conditionOperator has consulted the User Manual and/ or manufacturer specificationsOperator competency: (is operator competent on the use of this equipment?)

Check List: Cut Off/Concrete/Demo Saw *

All guards are in place Handle in placePPE for this specific tool provided

Can saw be used on trolley? *

YesNo

No, please provide more details *

Will this be used in a restricted or confined space? *

YesNo

Yes, please give more details *

Checklist Grinder *

All guards are in place Handle for grinderPPE for this specific tool provided

Please list PPE to be used *

Description of works and reason for use of restricted item *

Start and End date validation

Part 3 - Documentation

Safe Work Method Statement (SWMS/JSEA)

SWMS must be task specific, delete all the information not relevant to this job.

Please upload SWMS *

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Comments (optional)

Part 4 – Acknowledgement of Applicant

I confirm that:

I will comply with the ADG special conditions decided by the ADG authorised person.
I agree to repair any damage caused to the site or pay the costs associated with any repair work.
I agree to comply with all work health and safety requirements as outlined in our SWMS.
I will return my copy of this Permit for cancellation by the ADG Authorised Person, once work has been safely completed.

Name of Applicant *

Date *

Signature

Draw signature|Type signatureClear

Part 5 – Authorisation to Work

Is the permit approved? *

YesNoPending - More Information Required

Reason for disapproval/ Notes to the applicant *

Pending - detail of information required *this information will be returned to the application with a link to edit and resubmit.

Preliminary site inspection by Permit Approver *

YesNo Not Required

Part 6 - ADG Special Conditions

Provide details

Please upload relevant documents (if any)

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I authorise the works listed above to proceed during the specified dates and times only, in accordance with the ADG special conditions noted in Part 6 above: *

Date *

Name *

Email *

*Please fix the date above.

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