GAMA GÜÇ SİSTEMLERİ MÜHENDİSLİK VE TAAHHÜT A. Ş.

DISI – MUDAWARRA TO AMMAN WATER CONVEYANCE SYSTEM PROJECT

Serial No.: FORM 0003: PERMIT TO EXCAVATION

LOCATION:
Time &Date:

Section – I DETAILS OF THE PERMIT RECIVER

Permit Issued By Contact Number
Task Supervisor/Foreman Contact Number
Engineer Responsible Contact Number
Safety Supervisor on Site Contact Number
Section – II PERMIT VALIDATIONS

PERMIT ISSUE DETAILS Permit Valid For Section NO EXTENSION WILL BE GIVEN ON THIS

Permit Expired at Section PERMIT

Permit Contents: 1) Permit to Excavate ( two copies one for site one for Safety file)
2) Risk Assessment ( Copy for Site)
3) Personnel Training Record Sheet ( To be placed in safety file)
THIS PERMIT IS ONLY TO BE USED BY THE PERSONS TO WHOM IT IS ISSUED. ON COMPLETION OF THE TASK OR ON EXPIRY THE PERMIT IS TO BE RETURNED
TO THE ISSUER FOR CANCELATION after 7 days.

Section – III PREREQUISITE (Work May not commence if one of the following is not complied with)
 for YES and X for No Yes/No NA  for YES and X for No Yes/No NA
Is the Work Area Clearly Defined? Have the Latest DOC
A Services indicated by walk through with
drawings been Consulted?
H operatives designated to the task and safe
Has the Area been Scanned for Services with CAD exclusion zones been indicated by barriers.
B
Scanner?
Water / Sewer / Irrigation / Drainage
C Are All Service Locations Clearly Marked? I
( 1m Exclusion)
Have All Excavation area been barricaded by suitable
D Electrical 11 Kv or Higher Voltage
barriers and safety signs applied? J
(3m Exclusion)
Has a Risk Assessment Been Completed for all tasks of
E
excavation work? K Electrical Lower than 11 Kv (1m Exclusion)

Is there a safe method for entrance and egresses to the L Telecommunication (1m Exclusion)
F
confined space trenches (ladders)? M Oil/Gas (10m Exclusion)

Is there is safe controlling methods for environmental N Overhead Services (Contact Service owner)
G
pollution (dust, gases, fumes, etc.) O Other (including Structures)
Attended Briefing 1 5
2 6
Details of Employees working 3 7
in the Excavation 4 8
Name, Trade
Declaration by the Permit Issuer Planned Equipment For Allowed / Disallowed
Excavation

I_________________ representing _________________ hereby declare that I

have checked the location and all the employees have been briefed about the
emergency procedure and services associated with this area of excavation

Date: ……/……/…… Name; ……………. Signature; …………….. CANCELED: By:

Note: This permission is granted only after physical inspection of the site by HSE Supervisor and site Engineers.