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Alc-Hsef-12 - Permit For Lifting Operations - R00
Alc-Hsef-12 - Permit For Lifting Operations - R00
Company details
Company conducting Company managing the lifting
the lift operation
Crane Involved
Maximum lift
capable in Tones
Make / Model
supplied
configuration (consult Load Chart)
Registration / Plant Boom length to be
Metres
number used
Yes Yes No
Is the Load chart Is SWL indicator
available in the crane calibrated
No
____/____/20____
3rd party Certification- Certification due
last inspection date _____/_____/20_____ date ____/____/20____
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ALC-HSEF-012 Date: 05/01/2023 REV NO: 00 Page 2 of 3
Complete a separate form if more than one hook or configuration is used.
Lifting gear
Item ID Number SWLL Date thoroughly examined
_____/_____/20_____
_____/_____/20____
_____/_____/20____
_____/_____/20____
_____/_____/20____
_____/_____/20____
Visual check made
by (Rigger)
The Lift
What is to be lifted?
Place more detail on back
of form if required.
What is the weight of
lifting equipment used? Kgs
(Hook, spreader bar etc.)
What is the weight of the
items to be lifted? include Are other cranes Yes / No
more info on back of involved?
form if required
Site Conditions
What is the ground
Obstructions in lifting
angle at the lifting
location __________degrees
location?
0 degrees if level ground
Are the area concealing
Check ground
underground hazards?
conditions for
i.e. Pipes, recently back-
outriggers
filled etc.
Wind _______m/s
Could weather condition
Yes / No Rain light/heavy
affect this operation? If yes, give details of
the point where the
Area barricaded off to Other __________
operation will cease
prevent unauthorised Yes / No
access
Information
Name of
Pre-start toolbox talk
_____/_____/20____ supervisor
conducted
conducting
toolbox
Underground services
talk
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ALC-HSEF-012 Date: 05/01/2023 REV NO: 00 Page 3 of 3
documentation held Yes / No
Approvals
I have checked the above information as indicated and confirm that to the best of my knowledge, the
information is accurate and therefore this form is valid until the prescribed date, providing that conditions and
provided information has not changed.
Work can be stopped and Permit to work can be withdrawn by the safety officer if adequate safety requirements
are not Complied with.
Prescribed
Prescribed start ____________AM/PM ____________AM/PM
date/Time
date/Time
Valid until
_____/_____/20____ _____/_____/20____
I have inspected the work site and I certify that there is no suspended load on lifting equipment and all lifting
equipment brought to safe position.
Name: Signature
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