Doc No: BK9A-GEN-000-HSE-CRT-0004 Rev: A

Certificate No. SCAFFOLDING CERTIFICATE

VALID FOR THE DURATION OF THE PRIMARY WORK PERMIT ONLY
Location: Equipment:

Date: __________________
Work Platform Height: Time: __________________
Work Platform length and width:
Design criteria for scaffolding: Connected PTW/Certificate No.
Maximum intended load: ____________ kgs.
Maximum spans: ____________ mtr.
Ladder Rest Platforms spacing At every ___________ mtr.
Sole plates required beneath base plates Yes No

Ties and guy supports required Yes No Minimum spacing: ______________ mtr.
Plan and Facade Bracing required Yes No Maximum spacing: ______________ mtr.
Any concentrated load on the platform Yes No Additional posts/putlogs required Yes No Scaffolding Categorization:
Other Considerations Light Duty
Medium Duty
Hazards identified and addressed Yes No Heavy Duty
N/A
Soil/Ground firm, compact and level Special (specify)
Minimum clearance from overhead electrical lines maintained
Hazards from near by process equipment assessed and mitigated Type of Scaffolding
Effects of High winds, storms or rain assessed and mitigated Free standing tube & Coupler
Proper material hoisting and lowering methods adopted Supported tube & Coupler
Effects of High temperature equipment near by assessed and mitigated Tubular welded frame
Inspection of Scaffolding materials (pipes, clamps, planks, etc.) satisfactory Manually propelled mobile
Scaffolding Foreman and Scaffolders competent and certified Other (specify)
Scaffolding Tags available and used as required
Others (Specify) Scaffolding Sketch attached
TRA attached
PFAS Anchor/Tie off sketch attached
Scaffold Material Inspection Form attached
Other requirements Scaffold Inspection Report attached
Scaffolding inspection frequency Every shift/day/week/other _____________
Maximum number of people allowed on the scaffolding ______________ persons
Maximum tools and equipment load on the scaffolding ______________ kg PPE and Emergency Equipment
Full body safety harness
Shock absorbing lanyard
Twin lanyard
Details of Personal fall arrest system (PFAS) and Anchorage/Tie off point: Positioning belt and lanyard
Self retracting life line
Rescue/retrieval winch

Ensure at the scaffolding materials and equipment have been inspected before use.
Ensure the scaffolding has been inspected and tagged appropriately by competent person before allowing it to be used.

Certified Scaffolder (Name and Signature): _____________________________ _____________________________

Scaffolding Supervisor (Name and Signature): _____________________________ _____________________________

*Scaffolding Design Approved by (Name and Signature): _____________________________ _____________________________

*Only required in case design is equal or greater than 38 metres

Original : Performing Authority: Copy1: Permit to Work Station: Copy 2: CoW Office: