EXCAVATION PERMIT
SECTION 1: WORK REQUEST BY CONTRACTOR PERMIT NO:
CONTRACTOR: PERMIT REQUESTER:
LOCATION OF WORK: SIGNATURE:
EQUIPMENT TO BE USED/ TASK
DESCRIPTION:
SECTION 2: PRECAUTIONS/ GENERAL REQUIREMENTS
1. Prior to commencing excavation or trenching work, determine the location of all underground
installations(i.e.sewer, telephone, water, fuel, electric and gas lines.)
2. Excavations, trenching and adjacent areas shall be inspected by a competent person, after every
rainfall, as soil conditions change and as needed throughout the shift.
3. Stop/barrier to be provided to control the movement of the equipment.
4. Banksman to be provided to control the movement of the equipment
5. Overhead hazards are to be assessed and dealt.
6. Employees shall not work in excavations where water is accumulating unless adequate precautions have been
taken to protect employees against the hazard posed by the water accumulations.
7. If the stability of buildings or walls is endangered by an excavation or trench, shoring, bracing or
underpinning shall be provided
SECTION 3: HAZARDS / DANGER
Mechanical/Electrical hazards Collapse of soil
High temperature Scaffolding
Toxic / Flammable Gases Access / Egress
Contact with hazardous materials Banksman avilable
Heavy Equipment Movement Others
SECTION 4: APPROVED/ISSUED BY (Site Engineer / C M)
NAME SIGNATURE DATE TIME
PTW ISSUING
AUTHORITY
PERMIT COORDINATOR
PERMIT START(DATE&TIME) PERMIT END(DATE&TIME)
SECTION 5: ACCEPTED BY CONTRACTOR
WORK SITE Date:
SUPERVISOR Sign:
SECTION 6: DAILY VERIFIED
Date:
HSE OFFICER
Sign:
SECTION 7: PTW CLOSED
NAME SIGNATURE DATE TIME
PTW ISSUING AUTHORITY /
PTW COORDINATOR
REMARKS: On completion of the above mentioned works the permit must be returned by the
contractor who requested the permit.
HPH/HSE/Form
