To Use: ☐ Ladder/Step Ladder ☐ 120 V Power Tools ☐ Non-Cordless Power Tools 1. Project Information: (To be filled by initiator/originator of this Waiver) Project Name: Waiver No.: Requesting Contractor/Company: Sub-Contractor scope of work: 2. Waiver Issuance Details: (To be filled by initiator/originator) THIS WAIVER IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE Description of Task: Area / Location use: Period of use: Justify why Podium Platforms/ 110V cordless power tools cannot be used: Waiver will only be issued if there is no other alternative possible for the task Waiver Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date: Identification numbers for tools/equipment to be used: 3. Supervision Details: (To be filled by initiator/originator) Site Engineer responsible for the activity: Contact: Supervisor responsible for the activity: Contact: NOTE: This Waiver does NOT exclude the need for Permit to Work or all other pre-requisites. 4. Authorization (PM/CM) Name: Designation: Signature: Date/Time:

1. WAIVER FORM
Page 1 of 1 Form # HSEQ-WF (Rev 2 - Mar 23)
To Use: ☐ Ladder/Step Ladder ☐ 120 V Power Tools ☐ Non-Cordless Power Tools
1. Project Information: (To be filled by initiator/originator of this Waiver)
Project Name: Waiver No.:
Requesting Contractor/Company:
Sub-Contractor scope of work:
2. Waiver Issuance Details: (To be filled by initiator/originator)
THIS WAIVER IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Area / Location use:
Period of use:
Justify why Podium Platforms/
110V cordless power tools cannot
be used:
Waiver will only be issued if there is
no other alternative possible for the
task
Waiver Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:
Identification numbers for
tools/equipment to be used:
3. Supervision Details: (To be filled by initiator/originator)
Site Engineer responsible for the
activity:
Contact:
Supervisor responsible for the
activity:
Contact:
NOTE: This Waiver does NOT exclude the need for Permit to Work or all other pre-requisites.
4. Authorization (PM/CM)
Name: Designation:
Signature: Date/Time: