Area Authority Form copy · Permit To Work

PTW No.

AA Email

PICWS Name

PICWS Email

PICWS Mobile Ph

The following isolation certificates or requirement notices have been returned certified as having been complete and reactivated and returned to normal operation:

This permit can be closed out as per below

Close Out Outcome

Work has been completed. All tools and equipment removed and site returned to normal operations and Permit can be closed.
Work has not been completed and will now continue on new PTW No (issued by PIO).
Work has been suspended and site has been returned to normal operations.
The PTW has expired. A report has been issued to the Area Authority and PICWS requesting closure.
Work has been completed and PTW Closed pending receipt of documentation from Council.

New PTW No. if work is continuing

Sign Off

PICWS Sign Off

PICWS Sign off Date

Permit To Work Closure

The following isolation certificates or requirement notices have been returned certified as having been complete and reactivated and returned to normal operation:

This permit can be closed out as per below

Sign Off

Provide all relevant documentation