Five Star Scaffolding Pty Ltd
ABN 70 130 008 212
61 Long Street, Smithfield NSW 2164
(02) 9632 3466
Monthly Inspection
Project Details
What is this Certificate relating to ? Choose all relevant
*
30 Day (Monthly Inspection)
Other Works - mention in Notes below
What's the Project ID # ?
*
Which Building and what Level ?
What's the name of Customer or Builder ?
Customer ABN
How would you describe the work completed ?
Start Recognition
Pause Recognition
Scaffold Details
The scaffold described below has been erected in accordance with AS 4576 - Guidelines for scaffolding, AS 1576 (1-6) - Scaffolding, AS 1577 - Scaffold planks, Work Health and Safety (managing the Risks of Falls at Workplaces) Code of Practice 2015, Safe Work Australia - Guide to Scaffolds and Scaffolding. The scaffold described below is suitable for its intended purpose only.
All Hop-up’s can only be installed following the removal of the form ply deck below. The Principal contractor must ensure all falls are managed in the interim by either installing adequate edge protection or ensuring the ply is formed to the perimeter scaffold internal standards.
Hop-Ups are to be loaded to maximum capacity of 225Kg
Simultaneous loading permitted as per Scaffold Design
Is scaffold built as per Drawings Supplied?
*
Yes
No
N/A
What's the Loading Capacity?
*
LIGHT 225 KG
MEDIUM 450 KG
HEAVY 675 KG
SPECIAL DUTY
Which elevations were completed ? Choose all applicable
*
East Elevation
West Elevation
North Elevation
South Elevation
Lift Shaft
Base
Bird Cage
Roof
Void
Loading Platform
Whole Level
Whole House
Scaffold length
No. of Bays long
Scaffold Height
No. of Lifts Above Base Lift
Signatures
I acknowledge that I have read and understood and agree with the Handover Certificate Terms and Conditions. I have fully understood the Duty Category of the work platforms. Any breach of the Handover Certificate Terms and Conditions may result in an infringement of "Decommission of Scaffold Notice" being issued. Any breach of the Handover Certificate may lead to injury or death.
Checklist for Scaffold
1. Take Photos of Inspected area attach to report with signed Handover.
Yes
No
N/A
2. Jacks base plate centre to sole boards.
Yes
No
N/A
3. Face braces installed every 3rd bay.
Yes
No
N/A
4. End braces installed.
Yes
No
N/A
5. Kickboards installed correctly end bays fitted with external clips.
Yes
No
N/A
6. Face of scaffold level and plumb.
Yes
No
N/A
7. Stretcher stair correct position infills, lap plates, stair bolts, scaff tag, Handrails, step down at base, step off at floor level, correctly fitted.
Yes
No
N/A
8. Alloy stair correct position all Handrails secured with bolts step down in place scaff tag fitted.
Yes
No
N/A
9. Chain and shade fitted correctly looks neat and tidy.
Yes
No
N/A
10. Ties installed correct position.
Yes
No
N/A
11. Check gap from face of Building scaffold in correct position.
Yes
No
N/A
12. Housekeeping has area been cleared of left-over material and left clean.
Yes
No
N/A
13. Is the Z bar or Threaded Rod free from corrosion and damage ?
Yes
No
N/A
Name of person preparing this Certificate
*
Handover Date and Time
*
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Write your Customer email for them to receive a pdf copy
Write your HRWL number (High Risk Work Licence number)
Name of authorised Customer Representative
*
Signature of person Certifying
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