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This permit is valid for the time specified on the permit and must be
Completed by the person performing the work prior to commencement of any hot work
Used in conjunction with a SWMS or Safe work instruction
Checked by the GPNSW Representative prior to work commencing
Carried and produced when requested
Provided to the GPNSW Representative on completion of work for sign off
Part A Work Details
Name of permit requestor Business name
Contact Number Date of work
Location of work- Building
Special access restrictions
Description of work
A fixed fire protection or detection system will need to be taken out of service
(approval is required for the impairment and the Fire System Log Book is to be filled in
– see also GPNSW Authorisation below; approval contacts include:
The work area will require specific cleaning, purging, ventilating or pre-work
atmospheric monitoring (due to flammable/explosive vapours, dusts, liquids or solid
residues in the work area / location)
The work area will require pre-work cleaning, stripping, surface preparation,
or atmospheric monitoring during works (as a result of surfaces / coatings that
may create harmful emissions when heated or cut)
The nature of the work requires specific respiratory protection to be worn
The nature of the work requires specific controls to be implemented to
protect gas leads or other sensitive plant items involved in the work
The hot work involves arc-welding whereby specific controls relating to
ensuring electrical safety will be required
Section 3 – Implementation
Hot Works Authorisation (Work Coordinator in Direct Control):
The procedures, control measures and precautions appropriate for the safe execution of hot work have been implemented and the persons required to work
have been advised of and understand the requirements of the Risk Assessment & Hot Work Permit.
Name: Signature: Date: Time:
Constraints: This Authorisation is valid until the following occurs, or the date and time shown:
Date: Time: