Scribd
Upload
842 views

Excavation Permit Form

This excavation permit document contains details for an excavation project including: the project name and number of employees involved, dates and times for starting and expected completion, excavation depth and dimensions, identified risks such as falling, cave-ins, and underground utilities, required safety precautions and inspections, and signatures for issuance and acceptance of the permit. Personal protective equipment requirements are also listed.

Uploaded by

Karim Kachour
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
842 views

Excavation Permit Form

This excavation permit document contains details for an excavation project including: the project name and number of employees involved, dates and times for starting and expected completion, excavation depth and dimensions, identified risks such as falling, cave-ins, and underground utilities, required safety precautions and inspections, and signatures for issuance and acceptance of the permit. Personal protective equipment requirements are also listed.

Uploaded by

Karim Kachour
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

EXCAVATION PERMIT

PTW Ref .No: Date:


Project Name: No. of Employee involved
Starting From Date Time Expected Completion Date Time
Excavation / Trench Depth Length: Width:
Work Description:

Location of job to be performed:

Tools/Equipment to be used:
Identify risk associated this Excavation
Personnel Falling Underground Utilities Biological Noise
Falling Objects / Equipments Cave in (Collapse) Dust Vibration
Flood Adjacent Structure Heat Traffic
Other(Specify):
Precaution require to complete the work safely Yes No N/A
Is method statement attached with this permit?
Is risk assessment attached with this permit?
Are the equipments/machineries inspected and valid certification available for equipment & operator ?
Is the hard barrier given and safe distance (at least 1 meter from the edge of excavation) maintained?
Are type of soil identified? if yes mention below
Stable Rock Type A Type B Type C
Will the excavation be 5 or more feet deep and will personnel be entering? If yes, state below the
control measures been implemented:
Shoring Shielding Benching Sloping Details :
Will the excavation be 20 or more feet deep? If yes, Name of Professional Engineer ..............................
Are underground utilities checked below by means of appropriate detector through as build drawings,
and marked accordingly at the work location
Electrical Sewer Communications Storm water Gas Line
If underground utlities found, trial hole system (manual digging) is followed?
Are adequate inspection system followed for during, after excavation and backfilling?
Other (specify):
The following areas / items have been inspected by issuer and receiver
Access/Egress Danger/Warning Sign Lighting/Flickering Flag man
Detector (multi) As built Drawing Other (specify)
PPE Required for the activity
Helmet Safety Shoes Mechanical Gloves Safety Ear Plugs/muff
Safety goggles Reflective Vest Dust Mask Safety clothes
Gumboot Others (Specify):
Issue and acceptance before work
Acceptance of Work Permission by the person in-charge (Receiver)
Permit Receiver Name: Signature/Date:
Acknowledge by Contractor's HSE Officer
Name: Signature/Date:
Authority to proceed by authorized person (Issuer)
Permit Issuer Name: Signature/Date:

Name: Signature/Date:
Suspension
Name: Signature/Date:
Permit Re Validation
Clearance and cancellation after work or Suspension of permit Clearance. (PM/Site Manager)
EXCAVATION PERMIT
1.

2.

3.

4.

5.

Contractor's Verification by
Sl. Issuer Receiver
Date Time Safety SEC Remarks
No Signature Signature
Signature Consultant
1

This permit is valid for 7 days from the date of issue.

You might also like