Permit Request • CampusOptics

This form must be completed for all non-crane man or fork-lifts including, but not limited to, spider lifts, telescopic boom lifts, scissor lifts, articulating boom lifts, bucket trucks, telescopic fork lifts, etc.

IMPORTANT: Operator makes a service request if any item fails inspection.

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Aerial Lift Pre-Use Inspection

Pre-start Inspection Date:* Required

Project:* Required

Location:* Required

Type of Work:* Required

Lift Type:* Required

Model:* Required

Serial #:* Required

Lift Inspection

Operating Controls (in good working condition)* Required

Emergency Controls (shut off switches etc.):* Required

Safety Devices (anchor point, notification alarms, etc.)* Required

Personal Protective Devices* Required

Pneumatic, Hydraulic and Fuel System (leaks)* Required

Telescoping boom exhibits no damage to structure, wear pads, boom stops, or cylinder* Required

Cables in good condition/no excessive wear or fray* Required

Wiring harness free of fraying, damage, bare wires* Required

Tires/wheels in good operational condition* Required

Any Loose or missing parts* Required

Plackards and warning signs are in place* Required

Outriggers in good condition/support plates present* Required

Handrails/locking gate in place and not damaged* Required

Operator's manual in vehicle* Required

Charged fire extinguisher in place* Required

Work Area Inspection

Drop offs or holes* Required

Slopes* Required

Bumps/floor obstructions* Required

Debris* Required

Overhead obstructions and high voltage conductors* Required

Hazardous locations/atmospheres* Required

Tools and other equipment* Required

Adequate surface and support to withstand all load forces imposed by the aerial lift platform* Required

Wind and Weather Conditions: NOTE: operation of aerial lifts outdoors is prohibited when wind speeds reach 28mph, when there is a wind warning in effect for 28 mpoh or greater, when lightening is visible, or when thunderstorm warnings are in effect* Required

Presence of unauthorized persons* Required

Other possible unsafe conditions* Required

Additional Comments:* Required

Inspected by:* Required

Rescue shall be given to the MEWP occupant(s) if the machine is unable to be lowered for any reason, such as complete machine malfunction or work platform entanglement. In the case of platform entanglement, the operator and occupants shall be removed from the platform prior to attempts being made to free the platform. MEWPs which have tipped beyond their center of gravity shall be stabilized and secured before attempting rescue. *Rescue procedures near electrical conductors shall comply with local Minimum Safe Approach Distance (MSAD) Standards. Other MEWPs available for platform to platform evacuations as a last resort Rescue using another MEWP should be carried out only once a site review has been carried out. The plan should take into account the following: a. The rescue machine should be positioned to enable the rescue procedure to be carried out without compromising the safety of personnel involved in the rescue. b. The platforms of both machines shall be adjacent to each other with minimal horizontal/ vertical gap between them. The power to controls on both machines should be switched off during the c. The person being rescued should be fitted with proper fall protection equipment and maintain 100% tie off until the transfer is completed. d. The rescue machine shall not be overloaded during the rescue. This could mean making more than one trip to complete the rescue. e. Always comply with the manufacturer’s requirements stated in the operator’s manual.

CALLING 911 IS NOT CONSIDERED A RESCUE PLAN!

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files