UNIVERSITY OF WAIKATO – FACILITIES MANAGEMENT DIVISION
CONFINED and RESTRICTED SPACES PERMIT
The Job Manager shall ensure that:
- he/she is trained and competent to deal with matters of this nature
- the need to enter the space is confirmed
- the nature and inherent hazards of the space are assessed in conjunction with the
Contractor/Operative
- risks associated with the proposed work method(s) are assessed, also in conjunction with the
Contractor/Operative
- emergency response procedures are confirmed
- the competence of the operatives is assessed and confirmed as adequate
- work methods and control measures have been properly developed by the Contractor/Operative
This portion for the Job Manager to fill in:
Only one of the conditions may apply:
Permit for more than one day:
Permit for one day only:
Dates:
Date:
Area: Building …………………………
Level ……………………………..
Manhole No ……………………
Other ……………………………
Type of work being done ………………………………………………………………
……………………………………………………………
Times Work to commence ……………. Expected completion ……………………
Hazards identified ……….. Yes/No
(Details opposite)
Safety equipment on site … Yes/No Details:………….……………………………..
……………………………………………………………
Suitably trained & competent staff on site …………………
Yes/No
Staff in attendance outside the confined/restricted space …
Yes/No
Work procedures confirmed …………………………… …
Yes/No
Job Manager ………………………………….
…………………….
Signature
This is a non-transferable permit and is issued for one person and one job according to the
details on the permit
Emergency Numbers
Security:
838 4444
Revision: September 2004..
Job Manager:
1
Reference document: AS/NZS 2865:2001
This portion for the Job Manager and the Contractor/Operative to fill in :
Types of Hazards identified: (tick which ones apply)
Oxygen-deficient atmosphere
Oxygen-enriched atmosphere
Welding/cutting
Engulfment
Toxic atmosphere
Flammable atmosphere
Energised electrical equipment
Entrapment
Hazardous chemical
Safety Precautions not mentioned in Control Measures overleaf: (tick which apply)
Fire-retardant clothing
Fire extinguishers
Lighting
Lock-out or tag-out
Other remarks:
Control Measures which are required
---
details to be inserted overleaf.
The Contractor/Operative shall ensure that:
- he/she is trained and competent to perform work in confined/restricted spaces
- the nature and extent of the hazards of the space are confirmed as assessed
- control measures have been agreed with the Job Manager
- the work will be directly controlled at all times
- suitably-qualified personnel will be on standby (where this has been identified as a requirement)
- all staff will be provided with and will wear appropriate personal protective equipment
-
This portion for the Contractor/Operative to fill in
I have been advised of and understood the control measures and precautions to be observed
with the entry into this confined/restricted space:
Operative:
…………………………
Company: ………………………………………..
Signature:
…………………………
Date: …………………………………………..
Atmosphere Testing Limits:
Oxygen
Carbon Dioxide
Hydrogen Sulphide
Flammable gases
Revision: September 2004..
2
19.5% to 23.5%
less than 25 ppm
less than 10 ppm
less than 5%
Reference document: AS/NZS 2865:2001
See bottom of preceeding page for Atmosphere Testing Limits
Revision: September 2004 ...
3
Reference document: AS/NZS 2865:2001