Form HS10| Excavation Permit

|HSSE Management System

UNOPS Work Permit: Excavation

Estimated Time
Project Title
Required

Proposed
Location of Proposed
commencement
Works
of excavation

Details of Excavation
Permit Number
(including max depth)

Person in charge of
Excavation (name and Date submitted
title)

Underground and Overhead Services Checklist

Services Specific method,

‘As built’ Control zone
locations Services controls,
existing confirmed, Area to be
confirmed on require techniques and
services excavation scanned?
site and isolation? protection
drawings within?
marked required?

Electrical (in
ground)

Electrical
(overhead)

Water main

Gas main

Sewer system

Storm water
system

Data and
telecoms

Other?

General Considerations

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 Form HS10| Excavation Permit
|HSSE Management System

Yes No

Is area required for stockpiling sufficient and secure?

Are temporary barriers available to protect excavation?

Has risk assessment been carried out for the works?

Note: All archaeological items uncovered during excavation shall be immediately reported to the UNOPS site
representative. Work shall be stopped and waiting for further instruction from UNOPS site representative.

Authorisation

Signature of Approving Authority Time/Date of permit validity

Signature of Receiver Date

Completion

The work area is complete and has been left in a safe condition.
The work has not been completed and the following remains Date/Time
outstanding:

Permit Receiver:

Approving Authority: (permit returned and expired) Date/Time

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