Permit No.: Will the lift take place on or near a road? Yes No

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1 Applicant Details Full Name: Address: Start Date/Time: Company: 24 hr Contact No.: Completion Date/Time: Reason for Lift Location of Lift Is the lift within the BHF/Mineral Storage area? Yes No Will the lift take place on or near a road? Yes No Do you require other permits to complete the lift? Yes No Attach all relevant documents e.g. Lift Plan (Attachment A), JSEA, Licences, Tickets etc. Type of Lift Multiple crane lift? Yes No Lift over operating facility/building? Yes No Lift over or near power lines? Yes No Lift on wharf/berth/jetty decks? Yes No Does exceed 85% of crane max load rating? Yes No Lift near overhead structures? Yes No Type of Crane Max Outrigger Or Axle Load (In Tonnes) Crane 1: Crane 1: Crane 2 (if multiple lift) Crane 2 (if multiple lift) Requirements Checklist A licensed and competent operator has completed a lift plan that has taken into account the crane s specifications, outrigger loads, soil bearing pressure and any other computations required to ensure the lift is safe and there will be no environmental incidents or damage to property (Attachment A provides a lift plan template for those operators without a company template of their own). A Job Safety and Environment Analysis (JSEA), including a pre-lift checklist has been completed and signed by all operators. The JSEA is to be provided to all adjacent leaseholders and operators, as well as held on site at all times during the works. All lifts will have barricading, signage and lighting as per legislation, regulations and standards. All operators associated with the lift are licensed and competent to carry out the work. All associated permits have been considered All applicable equipment and services are certified and meet all current legislation, regulations and standards. Works on or Adjacent to a Berth Will the works be undertaken on or adjacent to a berth, near bollards or close to mooring ropes? Yes No If Yes, I have read and understood the dangers/hazards associated with working close to moored ships as highlighted in the MWPA Induction. If the lift location is on Berth 1, 2, 3, 4,5 or 6 the exact proposed crane position must be clearly marked on the drawing included in Attachment B V10 31 July 2017 Page 1 of 5

2 Engineering Assessment Comments: Approved/Additional Mandatory Conditions Rejected Revise and Resubmit Applicant s Acceptance of Conditions/Requirements By signing this document, the undersigned has read, understood and accepted the terms and conditions of this application and declares that all information given is true and accurate. Applicant Approval issued only when signed by authorised MWPA representative and processed by the Duty Wharf Supervisor MWPA Final Approval & Processing Approved by: Maintenance Supervisor Project Engineer Operations Supervisor Wharf Supervisor Approvers Name of Processor: Signature: Date: Office Use Only Recorded in Work Permits Register Date: Notify Operations Supervisor if in BHF/Storage Area Completion advised and site checked Date: Add to Daily Works Update Application closed Date: Review if other Permits required MWPA Terms And Conditions 1. Applicants are responsible for ensuring they have a BHF Authority to Work Permit (F4.1m) which can be obtained through the Operations Supervisor ops@midwestports.com.au or when working on Berths 4, 5 and in the BHF area. When working on Berth 7, authorisation must be provided by Karara Mining Limited. 2. Minimum 1.2 m x 1.2 m rigid outrigger pads with pliant bottom layers to ensure uniform contact is required for all lifts on wharfs and berth decks in accordance with the MWPA Wharf Specifications Booklet. 3. To ensure timely approval, the application must be lodged at least 2 normal business days (Monday to Friday) prior to commencement of the work. 4. Multiple crane lifts, lifts over operating facilities or buildings, lifts over or close to power lines, lifts involving personnel cages and lifts which meet or exceed 85% of the crane s maximum rated load will require approval on each occasion. All other lifts may be approved for multiple occasions within a 1 month period at the MWPA s discretion. 5. To complete this application you will require a current copy of the MWPA Wharf Specifications Booklet to determine loading on berth decks, as well as a services plan of the area to ensure no damage to underground services. These can be arranged via request to the Duty Wharf Supervisor on (0) or permits@midwestports.com.au at least 2 days prior to your intention to lodge the application. 6. No lift can commence until a signed approved form from MWPA has been received (either in hard copy or via ) and any additional conditions/requirements have been accepted. 7. Any safety or environmental incidents, or damage during works must be reported to MWPA immediately. After hours please call the Duty Wharf Supervisor on With regard to such incidents, you are responsible for making good the site and any other affected area to the satisfaction of the MWPA. 8. All personnel accessing MWPA sites are required to have completed the MWPA induction. Within the secure zone, individuals are required to carry their own Maritime Security Identification Card (MSIC) at all times. A visitor s pass may be obtained, although visitors must be escorted at all times by a holder of a current MSIC. 9. Any failure to gain approval for work, or failure to comply with MWPAs OHS-GUI-001 Contractor and Worker Requirements Handbook or Procedure 4.1 Permit to Work, may result in a penalty or permission to enter MWPA sites being withdrawn until all MWPA requirements are met. 10. No lift is to take place within 3 m of any wharf face, rock wall, retaining wall, excavation or similar without prior approval from the MWPA Engineering Department. 11. All appropriate measures to be taken to avoid damage to overhead or buried services and structures. 12. This permit is to be held on site at all times during the works. Should you have any queries, please contact MWPA Duty Wharf Supervisor on Completed permits should be ed to permits@midwestports.com.au. Custodian: HSEQ Manager V10 31 July 2017 Page 2 of 5

3 ATTACHMENT A - Crane Lift Plan 1. General Project: Location of lifting operation: Date/time of lifting operation: Who will be carrying out the lifting operation? 2. Details of the Load/s Description of the load/s: Overall Dimensions: Weight of Load: Kg/tonne Known Weight Estimated Weight Centre of Gravity: Obvious Estimated 3. Details of the Lifting Equipment Type of lifting equipment: Max SWL as Certified : Tonnes Date Last Certified: Max Boom/jib length: m Fly jib/offset: Max outrigger Loader: m Outrigger pad size: (refer to Wharf specification Book) Intended load radius: m SWL at this radius: Lift Percentage: (Distance between the load and the crane) 4. Personnel Involved in Lifting Operation Position Name Qualification/Experience Site Supervisor: Lifting Supervisor: Crane / Lifting Equipment Operator: Rigger: Dogman: Other: 5. Physical and Environment Consideration (Please Include Any Details In The Space Provided) Ground conditions: Yes N/A Ground made safe (e.g. placing steel plate)? Yes N/A Outriggers evenly extended? Obstacles: Yes No Are there any overhead obstacles such as power lines? Yes No Are there nearby buildings or structure, equipment or stacked materials that may obstruct lifting operation from being carried out safely? Lighting: Yes No Is the lighting condition adequate? Demarcation: Yes N/A Zone been barricaded (with warning signs and barriers) to prevent unauthorised access? V10 31 July 2017 Page 3 of 5

4 ATTACHMENT A - Crane Lift Plan Environment: Do not proceed with the lifting operation under the following circumstances: Thunderstorm and lightning strikes in the area. Ground condition checked after storm. Strong winds that may sway suspended load. Other circumstance (please specify): 6. Sequence / Special Precautions 7. Sketch of the Zone Operation (It is recommended that you include the initial location of the load, the final location and path of the load. It is also important to indicate any obstructions or equipment that may obstruct the lifting operation). If necessary, please use separate page for sketch to enhance detail. 8. Preparation And Review Prepared by: Time: Checked by: Time: V10 31 July 2017 Page 4 of 5

5 ATTACHMENT B Crane Location on Berth Note: Detailed berth deck crane load capacity plans can be viewed in the Wharf Specification Book available on the MWPA website under Publications & Forms: WHARF_SPECIFICATION_BOOKLET_Rev_H.pdf V10 31 July 2017 Page 5 of 5