OFF HOURS WORK PERMIT
Project Name
*
Please Select
DCC Land Base
Ecole Halifax Peninsule
CRA Saint John Fit-up
New Waterford Hub
Northside Health Complex
South Shore Regional Hospital
Transition Centre
PEI Mental Health & Addictions
RK MacDonald Nursing Home
QEII HVAC Upgrade
CUPE- St. Johns Office Relocation
New Atlantic District Office
DCC S32 Heritage Envelop Repairs
DCC D-20 Secure Room
CMMA Aircraft Maintenance
CMMA Aircraft Maintenance
DAL LSC Classroom Renovation
Summer Street Parkade
Ground Based Air Defence
Timberlea PP-8 School
Testing
Project Number:
*
Ask the PCL Superintendent.
Start Date(s) of Work:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
multiple dates can only be used for one week maximum
To
End Date(s) of Work:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
multiple dates can only be used for one week maximum
During this Off Hours Work Permit, the undersigned as the Designated Supervisor must be a Competent Person as set out in the Ontario Health and Safety Act and agrees to the following (check each box)
*
Ensure compliance with all PCL policies and the Occupational Health and Safety Act /Regulations.
Ensure that Public Safety is maintained at ALL times. Site fencing to be secured at all times.
Has reviewed the Project Specific Safety Plan.
Be present on site at all times while off-hours work is in progress.
Ensure that at least two (2) crew members are working together at all times.
At least one member has a valid First Aid Certificate, and a proper First Aid Kit is in an established location.
Ensure all workers, including the Supervisor, have attended the PCL Project Safety Orientation.
Description and Location of Work
*
0/282
Hazard ID and Review
*
0/282
Projected Hours of Work: From
*
Hour Minutes
AM
PM
AM/PM Option
Projected Hours of Work: To
*
Hour Minutes
AM
PM
AM/PM Option
Company
*
Applicant's Name
*
Applicant's Signature
*
Designated Supervisor's Name
*
Designated Supervisor's Signature
*
Designated Supervisor Cell Number
*
NAMES OF WORKERS - all workers must be listed.
*
Rows
Workers Name
1 (First Aider)
2
3
4
5
6
7
8
*A copy of this permit is to be submitted to PCL and another copy kept with the crew for the duration of the shift*
Work with the PCL Superintendent to fill out the following section.
PCL Superintendent (Name)
*
PCL Superintendent (Signature)
*
Signature Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PCL Primary Contact
*
Rows
Name
Phone Number
PCL Primary Contact
Site Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PCL Alternative Contact
*
Rows
Name
Phone Number
Alternate Contact 1
Alternate Contact 2
Alternate contact 3
*All incidents
must be reported
immediately to PCL*
In case of
emergency, call 9
1
1
Email Address?
*
A copy of the permit will be sent here.
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