NEOM Operations –Public

Facilities Management
Excavation Permit

Permit No.: Date Applied:

DOCUMENTATION REVIEW
Section – I General Information
Permit Category Standard Operational Emergency / Urgent

Requester Name Work Location

Minor Work
Contractor Name
Order # (If any)
Work Description
From (Date) To (Date) Total Days 15
Work Permit Coverage
From (Time) 7:00 Am To (Time) 5:00pm Total time 11
Associated Permit (If
General work permit
required)

Section – II Safety Requirement

All requirements mentioned below shall be completed and verified. If “Not”, please “Do Not” proceed.
Yes No N/A Yes No N/A
Does the work require announcement to 1-meter exclusion zone for electrical
1
the community? lines Lower than 11 kV/ telecom
9
Risk assessment and method statement services/Water / Sewer / Irrigation /
2 Drainage?
approved and provided?
Work area barricaded/ isolated with 3- meter exclusion zone for electrical
3 10
proper signages? lines 11 KV or Higher Voltage?
Underground service located and
4 Toolbox talk conducted before
drawing(s) available indicating services?
11 commencing the activity?
Safety Clearance from adjacent
5 Access route provided for utilities if
structures / FM team? 12
excavation blocking?
Excavation/trench protection planned
13
Underground installations are protected, and resources present?
6
supported, or removed if required? Overhead services identified and
14
zoned?
Hard barriers installed when
Valid Third-party certificate for operator 15
7 excavations are next to roadways?
and excavation equipment present?
Others
Cave-in required Controls in place as per
8 risk involve in the activity?
Use of Personal Protective Equipment
Method of digging / Excavation (PPE)

Trial holes / potholing Manual digging Machine digging

Hard Hat
Vest
Type of Protection Against Cave-in
Safety harness
Sloping Benching Shielding Safety Shoes
Trench Box Shoring Goggles
Type of Soil (in Tons per Square) Safety gloves
Coverall
 Type A >= 1.5 tsf unconfined compressive strength Respirator
 Type B strength Others (please specify).
 Type C =< 0.5 tsf unconfined compressive strength ________________________________

Section – III Permit Requester

I have personally inspected to ensure that all requirements & precautionary measures as mentioned above have been fulfilled.

Permit Holder Name

Emai mukhtar@diamond-
Signature l north.com
Designation Mobile No. +966 50 953 7016
Contractor
Contractor Safety Personnel
Name Mobile No. 0508385970
Email Signature
Page 1 of 2
Public
 NEOM Operations –Public
Facilities Management
Excavation Permit

JOINT SITE INSPECTION

Section VI Joint Inspection (Onsite)
Work will only commence after a HSFA site visit ensuring compliance with section II of the PTW and the controls advised within the Risk
Assessment & Method Statement (RAMS)
Remarks:

Permit Requester NEOM Proponent FM – H&S

Name Name Name

Signature/Date Signature/Date Signature/Date

Section – VII Holding/ Stoppage of Work

Reason (Holding / Stoppage) Stopped by Time Informed to Restarted time Signature

Section – VIII Extension

The work is not completed, and the renewal of permit requested for additional hours.
Reason for extension
Additional days from From (Date) To (Date) Total Days
Additional hours from From (Time) am / pm To (Time) am / pm Total time
Requestor
Name Email Mobile No.
Designation Signature Remarks
Approval (NEOM Proponent)
Name Email Mobile No.
Designation Signature Remarks
Approval (FM-H&S)
Name Email Mobile No.
Designatio
Signature Remarks
n

Section – IX Permit Closure

Note: I hereby confirm the completion of the work and any alarm, electrical, valves, etc. isolations/ LOTO have been removed. Work area is
left clean, tidy and safe for operational use.
Permit Requester NEOM Proponent FM – H&S
Name Name Name

Signature/Date Signature/Date Signature/Date

Page 2 of 2
Public