Gas Isolation Permit

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Acknowledgement Required

I confirm that this request to obtain a Permit to Work complies with Relevant Legislation and Curtin University Policies.
I have inspected the workplace, have determined and put into place appropriate control measures to minimize health, safety and operational risks, and I agree to accept full responsibility for these risks.
I have downloaded, read and understood the contents of:
Contactor Safety Handbook
Guide for Permit to Isolate Gas

I accept and acknowledge all of the above.

Documents Required

Only standard document types accepted. Please name files appropriately.
Combined document file size limit of 14MB.

1. Attach an Isolation Location Plan

2. Attach Services Plan/Survey Information

3. Attach a Work Methodology

4. Attach a Risk Management Plan

Isolation Details

The Curtin project number or project name

Brief description of works:

Isolation Duration

Daily

Extended - Daily Reinstatement

Extended - No Daily Reinstatement

Your Details Your Company's Name

Your Name

Your email address. We send important administration notices to this address

Your Contact Number

Curtin Permit Manager Details Your Curtin Permit Manager name

The information gathered from this form will be sent to this Curtin email address

Your Curtin Permit Manager phone number

Site Contact Details The Site Contact name

The Site Contact job title

On-Site Contact Number

I confirm that all of the supporting documentation and information contained in this permit request is complete and accurate.