Permit to use Stepladder

Site Gallions Quarter Phase 2B Subcontractor TRIANGLE

Requested by Location of
(Supervisor): works: Core G Level 3-4
Description of FIRE STOPPING
Task

Safety Checklist (All eight conditions MUST be answered YES) YES

The work at height hierarchy risk assessment has been completed and the most suitable working at height
access equipment been selected? YES
Does the step ladder confirm Class I or Class EN131 and of suitable size i.e. top of stepladder to be no
greater than 1 metre below the item being worked on? YES
Can the stepladder be erected on a smooth, even, non-slip surface? YES
Can 3 points of contact be maintained at all times? YES
Can the stepladder to be used without over-reaching? YES
Is the stepladder to be used by a competent operative who is familiar with the equipment? YES
Will the stepladder be visually inspected at the start of each working shift? YES
Has the stepladder been examined by a competent person (Supervisor) within the last 7 days? YES
5272
Please input an identification number so the ladder can be recognised i.e. serial number :______________________

Sergiu Miron-Ivan Curila

Name of operative who requires use of stepladder: ____________________________________________________

Authorised by:

Name:___________________________________ Position:___________________________________

Signed:__________________________________ Date:________________ Time:_________________

Receipt:

I have read and understand the special precautions to be taken prior to working at height
VITALII PRISACARI
Name (Supervisor):______________________________________
Vitalii 19.01.24
Signed:____________________________________ Date:______________ Time:__________________
8:00
Permit Closure:
I can confirm works involving stepladder have been completed and stepladder has been removed
from use.

Name (Supervisor):______________________________________

Signed:____________________________________ Date:______________ Time:__________________

Safety, Health & Environment Procedures July 2019