EXCAVATION WORK PERMIT
1. Specification of Work: -
Date __________________ Location of work _____________________________________________________________________
Description of work ______________________________________________________________________________________
Name of Equipment __________________________________ Number of Equipment ______________________________
Name of Permit Seeker (Contractor / Engineer/ Supervisor) _____________________________________
Permit required from AM/ PM ________________________ To AM / PM ________________________ (If time goes beyond 06:00
PM night work permit will be pop-up)
2. Mandatory requirements
Risk Assessment for Activity Tool box talk (If not available below portion will not appear)
3. Name & competency of work group involved
(Engineer, supervisor, Forklift Operator, Excavation Operator, Crane Operator, Helper, Technician, Supervisor, Foremen,
Vehicle Driver, Piling / DTH M/C Operator, Electrician / Lighting Technician, Welder, Gas Cutter, AC Technician, Chiller
Operator, Piping Technician, Grinder men, Security Staff, Store Keeper, Visitor / Guests, Civil worker/Helper, Medical (Para
Medics) staff)
Sr. Name Trade Training Records
1
No.
2
3
4. PPEs Required: -
Safety Helmet Reflective Jacket Safety Shoe Hand Gloves Goggles Dust Mask
Full Body Safety Harness Ear Plug Gum Boots Arc Flash Hood Arc Flash Suit
Welding Shield Welding Apron Face Visor Chemical Protection Suit Ear Muff
Electrical Safety Shoe High Voltage Electrical Gloves Chemical Resistant Gloves Chemical Resistant Apron
Chemical Respirator Shoulder Pad
5. Tools & Equipment: -
Life Line Fall Arrestor Safety Net Warning Tape Hard Barricading Horizontal life line
Vertical Life Line Descender kit Rescue Kit First aid kit Emergency Vehicle Signages
Fire Blanket Welding Blanket Retractor Fall Arrestor Block Tripod Gas Monitor SCBA
Induction Detector Earth Rod HV Line Insulator Under ground utility Locator LOTO Kit
Fire Extinguishers Spill Kit
6. Safety Isolation Required: -
Electrical Mechanical Chemical Radiation Water Gas Gravity
Format No: SW/HSE/F417
EXCAVATION WORK PERMIT
7. Weather Condition(If weather condition is not normal permit will not be issued)
Normal Foggy Windy Extreme heat Sand storm Heavy rain Extreme cold / snow Dark
8. Attachments
Drawing / Photograph STA MSDS Lifting Plan Rescue Plan TAKE 5
9. Control in Place
Check Points Yes No N/A Check Points Yes No N/A
Excavation Work
1. Excavation area is provided with barricade 2. Keep spoil dirt/material /equipment that
and Caution Boards may fall into excavation at least 2 meters
away from the edge
3. Safe access is provided to the excavated pit 4. Equipment are checked as per check list &
tagged
6. Checked for underground utilities
5. Barricading & Caution board to be do kept for
the excavated area if work not completed
7. Special instruction & restriction If any
__________ 8. Shoring required / available
9. Dewatering arrangement 10. Restriction on heavy vehicle movement
near excavated area
11. Condition of ongoing excavated pit & 12. Road closure & identification of
compactness of nearby soil condition emergency escape route
10. Name of Permit Issuer _____________________________________
All the above check points are verified & found ok & permit issued
From AM/ PM ________________________ To AM / PM ________________________ ; Permit not issued
Permit issued, work can be started
11. Permit Verified by (HSE department) _____________________________
All the required controls are found satisfactory. Permit continued
Permit conditions violated, unsafe act/ unsafe condition observed Permit on Hold
Satisfactory action taken Permit hold released
12. Permit Extension (Maximum 4 hours)
Comments: - ________________________________________________
Seeker ________________________ Approver _____________________
13. Permit Closure
Check Points Yes No
(If no comes permit will
not be closed)
1. No tools & waste material left inside equipment
2. Housekeeping satisfactory
3. Removal of barricades & restore the normal condition, guards, doors, nut bolts are
in place
Seeker ________________________ Approver _____________________
14. Permit Revoked
Adverse weather condition Emergency condition
Permit revoked by:- Project Manager HSE Department
Format No: SW/HSE/F417
