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Excavation Permit Form

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Kevs Macs
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21 views

Excavation Permit Form

Uploaded by

Kevs Macs
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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GEDI CONSTRUCTION DEVELOPMENT CORPORTATION

Rev No :
EXCAVATION/TRENCH PERMIT
Rev. Date: Page 1 of 2

PTW Ref .No: Date:


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

Location of job to be performed

Tools/Equipment to be used

Identify risk associated with Excavation


Personnel Falling Underground Utilities Biological Noise
Falling Objects / Equipment’s 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 / JHA attached with this permit?
Are the equipment’s/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?
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)
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 Name: Signature/Date:
Authority to proceed by authorized person (Issuer)
I reviewed the work permission checklist and checked the working conditions. I have reviewed all aspects of the task/activity and am satisfied
with the arrangements as detailed in the “job hazard analysis” that have been put in place and certify that the activity detailed above is authorized
to proceed
Site Manager Name: Signature/Date:
Acknowledge to 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:

Permit Re-Validation

Sl. Date Time Issuer Signature Receiver Signature Safety Signature Remarks
GEDI CONSTRUCTION DEVELOPMENT CORPORTATION

Rev No :
EXCAVATION/TRENCH PERMIT
Rev. Date: Page 2 of 2

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

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