L&T Technology Services
PepsiCo NE_GF
D0458801-V-CE-00-HS-FOR-
Excavation Work Permit D-04588-01-01
031
Name of Contractor: Report No:
Job No: Date:
Work Description: Location :
EXCAVATION WORK PERMIT Permit No: 00001
I. WORK PERMIT DESCRIPTION
1. Date: Time Start: Time End:
2. Job Description:
3. Job Location:
II. HAZARDS AND PRECAUTIONS
Hazards PPE Electrical Isolation Authorised Electrician
Burried Cables Helmet
Buried Pipelines Safety shoe
Loose soil Gloves - Cotton
Powder driller Goggles Service Isolation Authorised Operator
Traffic Safety Harness De pressurised
Trench Collapse Sleeved Crow bar Valve Closed & Tagged
Others SCBA Line Blanked
Others precuations Process Isloation Authorised Operator
Ladder & Scaffolding Valve Closed & Tagged
Equipment Varification Line Blanked
Barricading Line Disconnected
Proper Shoring Special Precautions
Proper Shuttering
III. PERMIT ISSUE AND ACCEPTANCE
Permit Requestor
I understand the workscope, Hazards, Precautions to be taken and ensure compliance
Name Sign Date: Time:
Maintenance Department
I Certify that the above equipment is isolated from every source of electrical energy and pipelines connected to
Name Sign Date: Time:
Acceptance by Contractor:
I understand the workscope, Hazards, Precautions to be taken and ensure compliance
Name Sign Date: Time:
Permit Authoriser
I have reviewed the workscope, Hazards and precautions and authorise for proceeding the work
Name Sign Date: Time:
IV PERMIT CLOSURE
Permit Requestor
The job described in this permit has been completed, all safety devices put back, area cleared and person on
the job withdrawn
Name Sign Date: Time:
Permit Authoriser
I have reviewed the worksite, satisfied and accept for closing this permit
Name Sign Date: Time:
Remarks
Contractor LTTS Client
Representative Representative Representative
Signature:
Name:
Date:
D0458801-V-CE-00-HS-FOR-031
