FIRE INDICATOR PANEL ISOLATION AND DEISOLATION PERMIT
Issue Date:01/07/16
ReviewDate:01/07/18




Section 1 and 2 To be completed by the person / company who is requesting / requiring the isolation
A risk assessment must be undertaken and attached to this permit along with a SWMS
The permit and risk assessment will be reviewed by an SHFA Authorised Officer
Section 3 to be completed by The Authorised officer of Property along with the Fire Protection Impairment Notification and
sent to the insurer as required through the Treasury Management Fund – fire impairment notification process.
 Section 4 is to be completed by the person responsible for isolating and de-isolating the fire panel
 A copy of this permit must be attached to the FIP while it is isolated.
 Responsibility for the safety controls listed in the risk assessment remain with the person requesting the isolation
1. Person requesting the isolation
Permit Number
(Building-FIPP-date)
Name of person requesting the
isolation
 Tenant
 Business Entity
 Contractor
(name)
Date of submission
Signature
Phone number
2. Isolation request details: complete and forward to Property
Building
Reason for isolation
Requirements (areas marked
with* will require insurance
company notification
Level/s
 Maintenance
 Construction
Isolation occurring under the
following conditions
Less than 12 hours only, during
business hours 6am-1800, less
than 20% of building isolated
(ie: daily)
Isolate for more than 20% of the
building
Name of person authorising
the isolation
 Yes*.  No
 Yes.  No*
Isolate overnight
 Yes.*  No
Isolate for more than 12 hours
(ie: continuous)
Isolation date
De-isolation date
Isolation time
De-isolation time
Indicate days
3. Authorisation (Facilities Use):
Room/s
 Mon.
 Tues.
 Wed.
 Thurs.
 Fri.
 Sat.
 Yes.*  No
 Sun.
* For isolation: Tresury Managed Fund must be notified under the
following conditions >20% building isolated, after hours, more than
one day through the Treasury Management Fund – fire impairment
notification process.
Use link to the notification
form
Certificate number & expiry
Date of authorisation
Signature
Phone number
4. Implementation
Name of person isolating the
FIP
Signature
Name of person
de-isolating the FIP
Signature
Custodian: WHS Manager
Approved by: Place Management
Number: SMS-02-FM-A1175697
Phone Number
Date of isolation
Time isolated
Phone Number
Date of de-isolation
Time de-isolated
Uncontrolled copy when printed
©GPNSW
Version: 1.0
Page 1 of 1