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Excavation Permit Form

This excavation permit document contains: 1. Details of the proposed excavation work including location, depth, length, width and expected start and completion dates. 2. Identification of risks associated with the excavation work such as falling, cave-ins, underground utilities, and requirements for precautionary measures and inspections. 3. Requirements for equipment inspection, maintaining a safe distance from the excavation edge, identifying soil types, and control measures for deep excavations. 4. A process for checking for underground utilities, inspecting the work areas, and listing required personal protective equipment.

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azozinlc
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Download as PDF, TXT or read online on Scribd
145 views

Excavation Permit Form

This excavation permit document contains: 1. Details of the proposed excavation work including location, depth, length, width and expected start and completion dates. 2. Identification of risks associated with the excavation work such as falling, cave-ins, underground utilities, and requirements for precautionary measures and inspections. 3. Requirements for equipment inspection, maintaining a safe distance from the excavation edge, identifying soil types, and control measures for deep excavations. 4. A process for checking for underground utilities, inspecting the work areas, and listing required personal protective equipment.

Uploaded by

azozinlc
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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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 1.5m or more 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)
I certify that, I have read and verified this work permit and checklist. I am aware of the risks that can be exposed to. I commit that I will be in line
with all safety rules mentioned in work permit checklist and will not deflect any of them.
Permit Receiver Name: Signature/Date:
Authority to proceed by authorized person (Issuer)
I reviewed the work permission checklist and checked the working conditions. I have reviewed the all aspects of the task/activity and am satisfied
with the arrangements as detailed in the “risk assessment” have been put in place and certify that the activity detailed above is authorized to
proceed
Permit Issuer Name: Signature/Date:
Acknowledge by Contractor's Safety Engineer/Officer
Name : Signature/Date:
Clearance and cancellation after work or Suspension of permit
Clearance. (Site Manager)
All men, materials, tools equipment, housekeeping etc. under my charge have been withdrawn. The permitted work is complete / not complete.
Name: Signature/Date:
Suspension
This permit is suspended, I have notified the Authorized person specified that the work is not complete the area / equipment is not safe to use.
Name: Signature/Date:
EXCAVATION PERMIT

List of additional precaution measures required (Supervision Consultant/ Contractor's Safety Engineer/ Officer)

1.

2.

3.

4.

5.

Permit Re-Validation

Sl. Receiver Contractor's


Date Time Issuer Signature Remarks
No Signature Safety Signature

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

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