VOLTAS LIMITED

EXCAVATION WORK PERMIT Permit No. & Date

Project & Unit: Emergency Contact Nos

Agency:

Exact Location of Work: ____

Nature / Description of Work:

Duration of Work Execution *: From Date: to Date: Daily from ___________ hrs. to ________hrs.
Name of Agency Performing the Work:
Name of Agency’s Site Supervisor (Permit Requesting Authority): Sign:

The above described work will be done under all the safety precautions mentioned on this permit to work as under during the
currency of the Permit.
Not required /
No. Item Yes Remarks
1. Precautions taken for Underground Electrical Cable
2. Precautions taken for Under / Above ground sewer/Drinking Water Line
3. Precautions taken for Underground Telecommunication Line
4. Precautions taken for Underground Product/Utility Line
5. Precautions taken for Underground Fire Water Line
6. Shoring / Shuttering / Sheet piling done to prevent collapse of excavation walls. Strength of
Excavation wall ensured at all times
7. Hard Barricading & Edge Protection provided
8. Separate Safe Access for Man and Vehicle
9. Lighting arrangement
10. Banks Man Provided
11. Required basic PPEs provided
12. Slope Cutting/Benching Maintained
13. Excavated soil / Construction Material / equipment kept away from the edge.
14. Emergency response team & Medical Facilities available.
15. Work hazards are identified, controlled and communicated to the worker.
16. Method Statements/ SOP/ Job Safety Analyses attached:

17. Other:

Declaration:
All the points mentioned in the above checklist have been checked and found OK.
Permit Receiver:
Site Engineer (Agency):
Signature:
Name: Designation:
Permit Issuer:
Site Engineer (VOLTAS):
Signature:
Name: Designation:

(* Permit valid for 7 days, subject to daily renewal, and extension as per overleaf instructions / record formats)

To be printed on both sides of an A4 Sheet Page 1 of 2

 Excavation Permit No. & Date:
___________________________
Daily Work Area Condition Endorsement
Signature with Date & Time Remarks
Sl. No. Date Agency Site Engineer VOLTAS Site Engineer
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Permit Extension Beyond Initially Requested Hours
Extension Period Signature with Date & Time
Sl. No. From……. To…… Remarks Agency Site Supervisor VOLTAS Site Engineer
(Date, Time) (Date, Time)
1.
2.
3.
4.
5.
6
Permit Closure After Work Completion
Permit is here by returned after completing the job & ensuring safe removal of men and material.

Site Engineer, Agency

Signature:
Name:
Verified the area is safe and Permit is Closed
Site Engineer, VOLTAS
Signature:
Name:
General Instructions:
1. Each Permit shall be given a unique number and recorded.
2. Method Statement/ SOP/ Job Safety Analysis for the critical tasks to be ensured by concerned
engineers and attached
3. Any other Work Permits required for the task to be taken and attached along with this Permit
4. Ensue that workers and supervisors involved are trained & medical checkup done
5. This permit must be available at the work site all the times of the work.
6. Location and description of the work must be clearly indicated by the permittee.
7. Terms applicable must be clearly indicated by the permittee.
8. This permit shall be endorsed each day by the agency and VOLTAS only after checking compliance to all points.
Any violations shall be resolved before proceeding.
9. Compliance to Permit conditions to be checked regularly by concerned execution department
10. Permit shall be issued for not more than 7 days including the issue date.
11. Permit shall be returned to the VOLTAS after completion of the job and closed.
12. All additional safety precautions to be taken as per HSE Management System.

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