ATTACHMENT J

YANSAB
SCAFFOLD PERMIT

Contractor ______________________ Area _________________________________ Date ___________

Specific Location ___________________________________________________Scaffold number __________

Supervisor __________________________________ Builder ___________________________________

(Print name) (Print name)

Purpose of Scaffold _______________________________________ Length of Time Needed ______________

Type of Scaffold_________________________________ Maximum Number of personnel Permitted _________

Height ________________ Length at Base _________________

Width at base __________________ Load Limit Maximum = Total Kg ________________________

Medium duty: Maximum Load Limit Kg = Width at Base X 2.5 meters length X 25 Kg/sq. meter
Heavy duty: Maximum Load Limit Kg = Width at base X 1.8 meters length X 34 Kg/sq. meter
Maximum Personnel = Maximum Load Limit (divided by) 360

NOTE: If a specialty scaffold or an engineer designed scaffold, the design drawing and specifications must be
attached.

PRE-ERECTION APPROVALS

The signatories below agree to the information above.

User ________________ Date ____________ Scaffolding Superintendent __________________ Date ________

Safety_________________ Date___________ Construction Manager ____________________ Date _________

SCAFFOLD COMPLETION

By signing here the scaffold builder verifies that the scaffold is complete, The scaffolding supervisor verifies that he has
conducted an inspection and confirms that the scaffold is complete and that is it being build according to the information on
this document and that the scaffold is ready for inspection. The user signs verifying that the scaffold is built according to his
needs.

Scaffold Builder ________________________________ Date Completed ________________

Scaffolding Supervisor________________________________ Date _______________________

Scaffold User ____________________________________ Date _______________________

AFTER ERECTION INSPECTION AND APPROVAL

By signing below the Scaffolding Superintendent and the Competent Scaffold Inspector certifies that the scaffold is complete, meets
all the scaffolding and safety criteria and that it is safe for use. The scaffold inspection form must be used for the inspection of the
scaffold. A completed green SCAFTAG must be attached to the scaffold at the access point with the scaffold number written on the
SCAFTAG.(In case of a specialty scaffold or engineered design scaffold or a scaffold 12 meter and above in height, the Scaffolding
Engineer must sign as the Competent Scaffold Inspector.)

Competent Scaffold Inspector ________________________________ Date _____________________

Scaffold Superintendent _____________________________________ Date _____________________

H:\000_General\Share\103\Safety\27j-Scaffold-Permit.doc