PERMIT FOR ACCESS TO ROOF

Permit Number

Date from Time from Job Location

Date to Time to

Brief Description of Work to be Done and Limitations (Hazards identified and controlled by RAMS)

PRECAUTIONS WHICH NEED TO BE CONSIDERED ON ROOF AREAS

(See overleaf and identify areas for approval, as well as circling the relevant Area Boxes below)

Area Type of roof / hazards Precautions

A

PART 1: ISSUE – To be completed by the Company Authorised Person

I have authorised access to the areas identified overleaf and the precautions to be taken are as defined. Access to areas not indicated
on this sheet is not allowed using this Permit. An additional Permit must be raised. I have seen the risk assessments and method
statements.
Authorised Permit Signatory Name (Block Capitals) Time Telephone Details

PART 2: RECEIPT – To be completed by Person in Charge of completing the work (Contractor/ employee)
I acknowledge that I have received this Permit and understand that I have access only to the areas indicated and that should I want to
gain access to other areas, I must gain an additional Permit.
I understand and agree to the precautions as stated.
Permit Signatory (Actionee) Name (Block Capitals) Time Telephone Details

PART 3: COMPLETION – To be completed by Person in Charge of completing the work (Contractor/ employee)
All personnel under my charge have been withdrawn
Permit Signatory (Actionee) Name (Block Capitals) Time

PART 4: CANCELLATION– To be completed by Company Authorised Person

Work checked and is completed to my satisfaction.
Authorised Permit Signatory Name (Block Capitals) Time

INCLUDE A GENERAL PLAN OF THE ROOF

TD F067-1 Roof Access Permit – St Leonards – April 2013