Appendix 1 - Safety Plan.docx

Appendix 1 Window Cleaning Plan of Service

Jobsite_________________________________________________Date____________________________

Contact Person at Site_______________________________________________________________________

Address___________________________________________________________________________________

City_____________________________________________________State_____________________________

Type Type of Window Cleaning to be Performed

|_| Post Construction |_| Scheduled Normal Cleaning

Type Type of Service to be Provided

|_| Both sides all windows |_| Outside Only |_| Inside Only

OtherOther Services Provided

On average, how many workers will be at the jobsite each day?______________________________

Name of lead person at the jobsite:________________________ Cell #:_______________________

EquipEquipment to be used for Window Cleaning

|_| Chemicals |_| Material Safety Data Sheet Available

|_| Ladders |_| Sectional |_| Extension

|_| Mobile Lift |_| Rental Unit

|_| Tower Scaffold |_| Rental Unit

|_| Pressure Cleaner |_| Rental Unit

|_| Tucker (High Reach) Washer

|_| Razor Scrapers

|_| Extension Poles

|_| Descent Equipment |_| Roof Rig |_| Anchors on Roof

|_| Suspended Scaffolding |_| Rental Unit

|_| Permanent Installation |_| Building Provided Certificate of Occupation

|_| Barricades/Danger Signs

|_| Other

Describe:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Desc Describe Where on the Building Each Piece of Equipment will be Used:

Equipment: Location:

List the Chemicals That Will Be Used:

Location of MSDS:

Type of Personal Protective Equipment to Be Used:

Describe Safety Hazards That May Be Encountered at Site for Each Piece of Equipment Being Used (Not High Rise) and List What Equipment or Method will be used to overcome the Hazard:

Equipment Hazard Location Solution

High High Rise Section:

Height of Parapet Wall: _______________________________________________________________________________

If Applicable, describe what fall protection equipment will be used: __________________________________________________________________________________________

8. Date of Last Inspection Provided by Building Management:_______________________________________________________________________________

2. If Transportable Rigging Equipment is being Used, Identify Anchorages or System to be used for Rigging, Tie Backs, Lifelines and their Location:

Permanently Installed Anchors Covering the Perimeter of Work Area? Yes No

Inspected on______________(Attach Copy) If no, the following must be Filled out:

Anchor Location

3. Has Bldg. Owner/Mgr. Verified Support Capability of above Listed Anchors? Yes No If Yes, Attach Copy:

4. If Transportable Rigging is not being Used, Identify Anchorages or System on Roof that will be used for Suspensions and Lifelines:

Permanently Installed Anchors Covering the Perimeter of Work Area? Yes No

Inspected on______________________________(Attach Copy) If No, the following must be filled out:

Anchor Location

5. Has Bldg. Owner/Mgr. verified support capability of above listed anchors? Yes No If yes, Attach Copy:

6. In the following space, draw a diagram that will mark the location of the anchor points to be used as described in sections three and four.

7. Roof sketch with identified anchor points, electrical supplies, restricted or dangerous areas and ground barricade locations: (attached)

8. Describe safety hazards that may be encountered and list what equipment or method will be used to overcome the hazard:

Equipment Hazard-Location Solution

Describe any or all rescue methods to be deployed in the event of an Emergency:

Describe an alternate plan if inclement weather affects safe working procedures:

Describe any special procedures required by the building owner/manager to follow during the operation:

Contractor Personnel completing form

Printed Name Signature Date

Signature of Government Representative completing form

Printed Name Signature Date