Excavation Work Permit
Permit No.: _____________________________ Date & Time: _________________
Project: ____________________________________________________________________________ Location: ______________________
Job Description: _____________________________________________________________________ Work Performed by: ____________
Permit Valid: Time from (Time to) ______________________________________
Section-I
SL No Description Yes/ No SL No Description Yes/ No
Underground utilities have been checked as applicable. Electrical /
1 Mechanical 11 Emergency plan is available and reviewed.
isolations are required
Method statement and Risk assessment is made Emergency Contact number is communicated and
2 12
for activity posted at location
Employees are safety inducted and trained prior Risk controls measures for fall prevention,
3 13
to activity commencement. collapse of excavation in place
Employees are in possession of the PPE Water/Oral dehydrate drinks is available
4 14
specified for the job as risk assessed. (Heat Stress)
Operatives are trained, competent the Soil bank piled no closer than 3 feet of
5 15
specific activity mouth of trench / excavation
Driver/ Operator must have valid driving license/ operating Excavated pit/ trench protection system, barricades 3ft
6 16
certificate from the edge, signage are in place.
If manual excavation are commencing, the operatives
Adjacent structures if present the impact is checked and
7 must have isolated tools and non 17
risk controls are in place.
conducive PPE's
Excavation side must be slope or step cutting to
8 Competent supervision is available at all time. 18
prevent soil collapse
Safe access and exit route to and from excavation is 1st use of equipment use the relevant checklist and
9 provided at diagonally 19 attached with the permit, prior commence
opposite ends. mechanical excavation
10 Permit is posted at the activity location. 20 Other:-
Section-II (Permit initiator /Requester)
Declaration: -
a. All the above safety precautions have been put in place, based method statement and HIRA/JSA verified by me on ground personally.
b. I shall ensure all the necessary precautions, till end of the work & I shall take full responsibility in case of any deviations or lapses noticed on site.
Details Name Signature Date & Time
Permit Initiator/ Requester
Engineer/ Supervisor:
Checked & Conformed by
Safety Officer: Comments if Any:
Reviewed & Approved by
PMC/ Client:
Section-III (Permit Closure)
Declaration: -
The above-mentioned job has been completed in satisfactorily. Date…………………………………. & Time..................................this permit is closed.
Details Name Signature Date & Time
Permit Initiator/ Requester
Engineer/ Supervisor
Checked & Conformed by
Safety Officer
Reviewed & Approved by
PMC/ Client