Doc. Code OP20-013-F01vers 4.0, 09-09-2014Page 1 of 4

Authority to Work Application Form

Application Number: (Queensland Motorways Office Use Only) QMM - ATW /2014 Date Received:

New Application for:

Road access Gantry access Construction work

N Roadside access Building access Maintenance O I T Application for Bike path access Special event A Bridge access C I

L Bridge cavity access Pedestrian path access Emergency P P A Extension/amendment to existing ATW Permit: QMM - ATW /2014

Organisation Name of organisation

Street no and street name Address S

L City and postal code I A T

E Phone Number 00 0000 0000 D

Authorised

T representative for this Name N Mobile Phone A application 0400 000 000

C Number I L P

P Email Email Address A

Mobile Phone On site contact person Name Number 0400 000 000

Queensland Motorways Other Queensland Motorways Contract Number: Company Name: Queensland Motorways Project Manager Name: Company Contact Name: T N

E Queensland Motorways Project Manager Company Contact Phone: M

E Phone: Engaged by: G A G

N Are the activities as per an Access or Interface Agreement with Queensland Motorways? E

Yes Agreement Number: Date of Agreement: Agreement description: No

Name (road / structure / Include a short description of the proposed location building, etc) N O

I Direction Northbound Southbound Eastbound Westbound T A C

O Landmark Description Example: about 100m north of Miles Platting Road overpass L

Date From: Date To: Date

Requested times eg Sun-Thurs 20.00 - 05.00

Doc. code OP20-013-F01 Vers 4.0, 09-09-2014 Page 1 of 4 Authority to Work Application Form

Description of the Include a detailed description of the proposed activities (or attach a word document with activities for this permit detailed description)

Tolling Gantry Is the activity or required traffic control within 40m of a tolling gantry? Yes Details: No

Does the activity require a closure of a tolling gantry? Yes Details: No

Potential environmental Soil Disturbance Water Waste impact? (Tick Dust/Odour/Smoke Contamination Noise appropriate box) No Vegetation Disturbance Wildlife Disturbance Bushfire S

E Weeds/Fire Ants Cultural Heritage I T I V I Will your activities Yes (please indicate the activity by selecting one or more of the following T No C involve any of the options) A following? D

E Traffic Lane Closure S Powered and mobile plant O Working on or adjacent to P

O traffic (roadside or behind a road Hazardous substances or dangerous goods R safety barrier) P Demolition or structural alterations Road/Roadside Inspections using vehicles at a reduced speed Work near water or waterways in live traffic Asbestos Exiting and entering a vehicle Working at heights from the Motorway Bridge cavity entry Trenching or excavations Confined space entry Energised or electrical work Construction work Pressurised gas mains Hot work Telecommunications Towers

Note: A Safe Work Method Statement addressing the above activities and a map detailing at which point you will access site must be submitted with the application for review by QMM.

Is a carriageway closure required? Yes No

Is a lane closure required? Yes No Number of lanes: Number out of Number L

O Is a ramp closure required? Yes – Name of ramp? No R T N

O Is a partial ramp closure required? Yes – Ramp Name: Name of ramp No C

I Number of ramp lanes closed: Number out of Number F

F Road Impact A No R Is a shoulder closure required? Yes T ) e l Is a median closure required? Yes No b a c i l

p Slow/Stop control Mobile works Detour works p a

( Traffic Management Plan and/or Traffic Guidance Scheme attached TMP/TGS Reference Number(s):

Required speed Existing Speed Limit or km/hr

1) The signatory warrants that he/she is authorised to sign on behalf of the Applicant. 2) This Authority to Work Application is made to Queensland Motorways Management Pty Ltd (QMM) who is acting on behalf of relevant members of the Queensland Motorways group in its capacity as service provider to those members. All representations made, and indemnities provided, by the Applicant to QMM are also made, and provided for, the benefit of the relevant members of the Queensland Motorways group, and are relied on those members in granting any Authority to Work through QMM. Any Authority to Work will be issued by QMM on behalf of the relevant members of the Queensland Motorways group. 3) No activities shall commence until an approved signed Authority to Work permit is issued and received by the applicant. 4) The Applicant shall indemnify QMM, and any relevant member of the Queensland Motorways group, against any claims, loss or damage arising out of any activity associated with this Authority to Work. 5) QMM will hold the Applicant responsible for any damage caused to QMM’s, or any relevant member of the Queensland Motorways group’s, assets by the activities. 6) QMM does not accept any responsibility for damage to property or injury to any person or repair work resulting from the activities carried out by the approved Applicant or a person acting on behalf of the approved Applicant. 7) The Applicant is responsible for all aspects of site control and safety. 8) The Applicant will be responsible for reinstating the work site to the satisfaction of QMM. 9) If the activity includes traffic control:

N a) a traffic guidance scheme which details the traffic control devices to be implemented must be available for the O I proposed activity. It must be produced in accordance with DTMR MUTCD Part 3, current edition and Work Health and T

A Safety Act 2011. If any traffic diversion is required, detour signage and detour map/s will be provided as part of the C I application; L

P b) the Applicant must engage a Traffic Management Company currently registered with the Department of Transport and P A

Main Roads. All traffic controllers must be suitably qualified to assist in traffic control; F c) the Applicant/contractor must monitor the surrounding traffic flow and should there be any significant queuing (i.e. the O

S queue extends to the first set of roadworks signs), the Applicant/contractor shall clear the area and allow traffic queues

N to clear before resuming work/activity. In these circumstances, the Applicant/contractor shall phone the Queensland O I Motorways’ Traffic Management Centre (ph. 3323 0101) and advise when the site is cleared and when the works T I

D resume. N

O 10) The Applicant must notify any other interested agency (e.g. QPS, DEHP, Emergency Services, local authority, DTMR) of C the proposed work. The required permits/approvals will be obtained before any activity commences. 11) Public liability insurance cover must be in place prior to the activity commencing, as follows: a) for construction/maintenance contractors (major/medium risk) an amount not less than $10 million; b) for facility tradespeople (minor risk) an amount not less than $5 million. 12) The Applicant/contractor must advise Queensland Motorways’ Traffic Management Centre (TMC) (phone 07 3323 0101) at the following times: a) One hour before any activity commencing in the starting day; b) Upon completion of the proposed activity; c) Immediately in the event there is any incident/ accident or unexpected disruption to traffic at or near the work site. 13) The Applicant must inform QM’s Authority To Work Co-ordinator of any change in the operating conditions (operating times, dates, duration) and of any requirements to adjust the approval. A re-submission of the Authority to Work Permit Application may be required. 14) The proposed activity must not cause, or be likely to cause, environmental harm, whether from release of waste, contaminant, weed, pest, dust, noise, sediment; or through the disturbance of native flora / fauna or heritage item. Any detrimental events resulting from such activities will be promptly and appropriately responded to and immediately notified to Queensland Motorways’ TMC. QMM reserves the right to claim or withhold expenses incurred for remedial works deemed necessary to mitigate environmental harm from parties responsible. 15) The approved ATW Permit must be present at the activity site at all times.

N  Please allow 10 working days to process this application. Applications for ‘emergency’ will be treated as priorities, O I

T normally within one or two working days. A

C  By submitting this application, the Applicant is consenting to agree to the ‘Conditions of Application’ identified above. Such I

L conditions will apply and the Applicant agrees to comply with these conditions if the application is approved and QMM P

P issues the Applicant an Authority to Work permit. The Applicant can appeal any of these conditions in writing. The appeal is A to be attached to the application. F O

 Application to be submitted to: QUEENSLAND MOTORWAYS MANAGEMENT PTY LTD – ROAD OPERATIONS N O

I Email: [email protected] or Post: PO Box 2125 Mansfield Q4122 S S I M

B Signature of authorised representative of Applicant Not required if by email Date U S

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