OFFICE USE ONLY
Design Registration Number
Government
of Western
Australia
Government
of Western
Australia
Department
of Commerce
Department
of Commerce
Lodgement Number
Application 100
Registration of Plant Design or Alteration to Plant Design
Regulations 4.3 or 4.12 of the Occupational Safety and Health Regulations 1996
1 APPLICATION FOR REGISTRATION
To be completed in conjunction with explanatory notes
1.1 Original Design: Regulation 4.3
1.2 Alteration to Design: Regulation 4.12
Registration No:
State…………………..
State
2 PLANT DETAILS
2.1 Kind of Plant
2.2 Design Standard
2.3 Plant Type
2.4 Plant Description
3 APPLICANT DETAILS
3.1 Name
3.2 ACN
3.3 Address
Suburb
State
3.4 Contact name
Tel
Fax
Email
Post Code
3.5 I, representing the Designer
, Owner
, Manufacturer
, Importer , Supplier
, of the plant described in SECTION 2.1 submit this
application for registration of the plant design or alteration to design described herein. I declare that the information contained in this application is true
and correct to the best of my knowledge and belief.
Print Name
Signature
Date
4 DESIGNER DETAILS
4.1 Name
4.2 ACN
4.3 Address
Suburb
State
Post Code
5 DESIGNER STATEMENT
5.1 Name
5.2 ACN
5.3 Address
Suburb
State
5.4 Contact name
Tel
Fax
Email
Post Code
5.5
The person
duties
under
Regulation
4.234.23
of the
who designed
or altered
the design
thethis
plant
must sign
this designer statement.
5.5 The
personwho
whocarried
carriedout
outthe
the
duties
under
Regulation
of person
the person
who designed
the plant
must of
sign
designer
statement.
If the person who designed or altered the design of the plant described in SECTION 2.1 is not in the jurisdiction of Western Australia then the
If the person who
the plant is
described
in the
SECTION
2.1 isofnot
in the Australia,
jurisdictionthen
of Western
Australia
the
manufacturer,
or if the
manufacturer,
or ifdesigned
the manufacturer
also not in
jurisdiction
Western
the importer
of thethen
plant
into
Western Australia
shall carryout
the
designer’sisduties
under
Regulation
4.23.
manufacturer
also not
in the
jurisdiction
of Western Australia, then the importer of the plant into Western Australia shall carryout the designer's duties
under
Regulation
I,
the Designer
n 4.23.
Manufacturer n Importer n responsible for carrying out the duties of the designer for the plant design or alteration to the design
described in SECTION 2.1 state that the answers I have provided are true and correct and that I have complied with the duties that a person who
, Manufacturer
, Importer
responsible for carrying out the duties of the designer for the plant design described in SECTION 2.1
I, the Designer
designs plant has under Regulation 4.23 of the Occupational Safety and Health Regulations 1996.
state that the answers I have provided are true and correct and that I have complied with the duties that a person who designs plant has under
Regulation
Print
Name4.23 of the Occupational Safety and Health Regulations 1996.
Signature
Date
Print Name Office use only
Signature
Initial
Date
Date
COM
OK
Pre check
To issue
CSC-FM 100.01 Version 2
Page 1 of 2
File: 86779
CSC-FM 100.01 Version 5
Page 1 of 2
WS0419/2006
Government
of Western
Australia
Government
of Western
Australia
Department
of Commerce
Department
of Commerce
Application 100
Application 100
Registration of Plant Design or Alteration to Plant Design
Registration of Plant Design or Alteration to Plant Design
Regulations 4.3 or 4.12 of the Occupational Safety and Health Regulations 1996
Regulations 4.3 or 4.12 of the Occupational Safety and Health Regulations 1996
6 REPRESENTATIONAL DRAWINGS OF THE PLANT DESIGN OR DESIGN ALTERATION
6
OF THE
ALTERATION
REPRESENTATIONAL DRAWINGS
No.
Rev.
Rev.
No.PLANT DESIGN OR DESIGN
No.
Office use: P F - F F
Office use: P F - F F
Rev.
Rev.
Rev.
Rev.
7 DESIGN VERIFIER DETAILS
7
VERIFIER DETAILS
7.1DESIGN
Given names
Office use: P F - F F
Office use: P F - F F
8 DESIGN VERIFIER STATEMENT
8 DESIGN VERIFIER STATEMENT
Office use: P F - F F
Office use: P F - F F
No.
No.
No.
Rev.
Rev.
Rev.
No.
No.
No.
Rev.
Rev.
Rev.
No.
No.
No.
Surname
7.1 Given names
Surname
7.2 Qualification (s)
7.2 Qualification (s)
7.3 Business Address
7.3 Business Address
Suburb
State
Post Code
Suburb
State
Post Code
Tel
Fax
Email
Tel
Fax
Email
7.4 Employer (Legal entity name)
ACN
7.4 Employer (Legal entity name)
ACN
7.5 Is the employer of the design verifier also the employer of the designer: YES
NO
7.5 Is the employer of the design verifier also the employer of the designer: YES
NO
7.6 How many design verifiers involved in the design verifying process [
] Attach details (7.1 to 7.5) for each additional design verifier.
7.6 How many design verifiers involved in the design verifying process [
] Attach details (7.1 to 7.5) for each additional design verifier.
1)
1)
2)
2)
The design or design alteration of the plant described in SECTION 2.1 complies with each relevant Standard set out in Schedule 4.3,
The design or design alteration of the plant described in SECTION 2.1 complies with each relevant Standard set out in Schedule 4.3,
NO
specifically those Standards set out in SECTION 2.2, without exclusion of any relevant design requirement of each Standard: YES
specifically those Standards set out in SECTION 2.2, without exclusion of any relevant design requirement of each Standard: YES
NO
The design or design alteration of the kind of plant described in SECTION 2.1 is for pressure equipment: YES
(If
(if YES go to 3) NO
The
design
or design alteration of the kind of plant described in SECTION 2.1 is for pressure equipment: YES
(if YES go to 3) NO
(If
NO sign
below)
NO sign below)
NO
3) Verification of the pressure equipment design has been carried out in accordance with AS3920.1: YES
NO
3) Verification of the pressure equipment design has been carried out in accordance with AS3920.1: YES
I, the verifier of the design or design alteration for the kind of plant described in SECTION 2.1, state that the answers I have provided are true and
I, the verifier
of the
or design
alteration
for thedescribed
kind of plant
described
in set
SECTION
2.1, state 6that
the answers
I have
provided are
true
and
correct
and that
thedesign
plant design
or design
alteration
in the
drawings
out in SECTION
complies
with the
requirements
of the
Standards
correct
and
that the 4.3
plant
or design alteration
described
in the drawings
setspecifically
out in SECTION
6 compliesset
with
Standards
set
out in
Schedule
of design
the Occupational
Safety and
Health Regulations
1996,
those Standards
outthe
in requirements
SECTION 2.2.of Ithe
state
that in
set out in this
Schedule
of the Occupational
Safety
Healthout
Regulations
1996,
specifically
those
Standards
outinvolvement
in SECTION
I state or
that
in
providing
design4.3
verifier’s
statement that,
whenand
carrying
the duties of
the design
verifier,
I have
not hadset
any
in 2.2.
the design
design
providing this
design
statement
that,2.1.
when carrying out the duties of the design verifier, I have not had any involvement in the design or design
alteration
of the
plant verifier’s
described
in SECTION
alteration of the plant described in SECTION 2.1.
Print Name
8.1 Signature
Date
Print Name
8.1 Signature
Date
9 ADDITIONAL DESIGN DETAILS
9
1) ADDITIONAL DESIGN DETAILS
1)
3)
3)
5)
5)
To be completed in conjunction with explanatory notes.
2)
2)
4)
4)
6)
6)
Method
of Payment
The fee for this application is specified in the Occupational Safety & Health Regulations 1996, Schedule 6.2 and is exempt from GST. Cheques to be
The
in the Occupational Safety & Health Regulations 1996, Schedule 6.2 and is exempt from GST. Cheques to be
fee
for thistoapplication
specified
made
payable
WorkSafeisWestern
Australia.
made payable to WorkSafe Western Australia.
Please choose one of the following options for payment:
Cash
Cheque [Cheque No
.]
Please choose one of the following options for payment:
Cash
Cheque [Cheque No
.]
Postal Money Order
Please charge payment of this application to my:
MasterCard
Visa
Please charge payment of this application to my:
MasterCard
Visa
Postal Money Order
Card number F F F F F F F F F F F F F F F F
Expiry date F F / F F
Card number F F F F F F F F F F F F F F F F
Expiry date F F / F F
Name of card holder ___________________________ Signature
Name of card holder ___________________________ Signature
Payment details (Tax invoice: Department of Consumer and Employment Protection ABN 91 329 800 417)
Payment details (Tax invoice: Department of Consumer and Employment Protection ABN 91 329 800 417)
You can submit this completed application form for Registration of Plant Design or Alteration to Plant Design in one of two ways:
th
You can submit
completed
application
formAustralia,
for Registration
of Service
Plant Design
or WestCentre
Alteration to 5Plant
Design
in Hay
one Street,
of two ways:
•
Floor,
West Perth
1260
Inthis
person:
WorkSafe
Western
Business
Centre,
th
• • In person:
Hay
Street, West
Perth
Western
Australia,
Business
Service
Centre,
Level
1, Mason
Bird
Building,
303
Sevenoaks
Street,
Cannington WA 6107
In
WorkSafe
Western
Australia,
Business
Service
Centre,
5 Floor,
Byperson:
mail:WorkSafe
WorkSafe
Western
Australia,
Business
Service
Centre,
POWestCentre
Box
294, West
Perth,1260
WA
6872
• Information:
• By mail:
WorkSafe
Western
Australia,
Business
Service
Centre,
Bagwww.commerce.wa.gov.au,
14, Cloisters
Square
By mail:
WorkSafe
Western
Australia,
Business
Service
Centre,
Box
294,
West Perth,
WA WA
68726850
Further
WorkSafe
Business
Service
Centre,
Phone:
1300
307 Locked
877,PO
Web:
Email: [email protected]
Further Information: WorkSafe Business Service Centre, Phone: 1300 307 877, Web: www.commerce.wa.gov.au, Email: [email protected]
File: WS0419/2006
CSC-FM 100.01 Version 5
Page 2 of 2
WS0419/2006
File: WS0419/2006
CSC-FM 100.01 Version 5
Page 2 of 2