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Excavation Work Permit Form

This permit document outlines the requirements and safety precautions for a work activity. It includes: 1) Details of the contractor, location, and description of work. 2) Confirmation that a safe work procedure and hazard identification was provided to workers. 3) A checklist of 12 safety precautions to be verified like underground utility surveys, risk assessments, ground stability calculations, barricades, fall protections, and personal protective equipment. 4) Sections for the contractor to request the permit, an approver to recommend approval, a project manager to approve, and to sign off once completed.

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norafikatolah1992
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178 views1 page

Excavation Work Permit Form

This permit document outlines the requirements and safety precautions for a work activity. It includes: 1) Details of the contractor, location, and description of work. 2) Confirmation that a safe work procedure and hazard identification was provided to workers. 3) A checklist of 12 safety precautions to be verified like underground utility surveys, risk assessments, ground stability calculations, barricades, fall protections, and personal protective equipment. 4) Sections for the contractor to request the permit, an approver to recommend approval, a project manager to approve, and to sign off once completed.

Uploaded by

norafikatolah1992
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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PERMIT TO WORK

Permit No.

SECTION I
Apply for activity: Location :
Contractor : Trade :
Standing Supervisor: H/P No.:
The permit is request from : (Date) On : am/pm
The permit is valid until : (Date) On : am/pm
Description of Work:

SECTION II
A Safe Operating Procedure/ HIRARC has been provided and clearly train to workers in TBM before works
YES NO

SECTION III
SAFETY PRECAUTIONS TO BE CARRIED OUT : (Circle one and initial) To be filled up by the
Site Supervisor together with Approver:
No Description Observation Initial
1 Has survey been carried out to confirm underground utility services Yes/No
2 Has Risk Assessment been carried out to identify potential hazards, risks and
Yes/No
control measures
3 Has the Competent Engineer produced the ground stability calculation Yes/No/NA
4 Work area is barricaded and warning signs displayed Yes/No
5 The barricading tape is reflective and illuminated at night Yes/No
6 Have all the excavation area been installed with Toe-Board to prevent falling object i Yes/No/NA
7 Has the excavation been battered or benched or shored Yes/No
8 Safe access and egress from and to the excavation is provided Yes/No
9 All heavy equipment and vehicles are kept 2 meters away from the excavation Yes/No
10 All workers are wearing Helmet and Safety shoes Yes/No
11 Have all the workers been Safety Inducted and has Site Pass Yes/No
12 Have all the workers involved been trained in Excavation Hazards and Controls Yes/No

Other Precautions:

SECTION IV
PTW Request by (contractor supervisor / SSS) Job Cancellation :PTW Cancellation / Failed (SHO)
I hereby agree to be supervise and responsible for this activity and I have checked and confirmed this PTW application is failed /
will make sure my team members comply to the requirements stated cancelled. This permit is now cancelled.
in this permit.
Sign: Sign:

Name:
Name:
Date: Time :
Date: Time :

Issuance Approval : Recommended Approval (SHO) Issuance Approval : Approval and Authorization (PM)
I recommended the approval of the work operation and executed
I hereby approve the work operation to be executed safely.
safely.
Sign:
Sign:

Name:
Name:
Date: Time :
Date: Time :

SECTION V
Job Completion
The job has been completed. Housekeeping has been carried out and original condition has been restored.

Sign:

Name:
Date: Time :

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