Document: SP-31-RF-04

Issue: 01
Excavation Work Permit Request Form Issue Date: Feb 08, 2024
Page: 1 of 1

Work Order No: ________________ EXCAVATION WORK Excavation Work Permit No: ___
Location: _ _ PERMIT Issue Date ___________________

SUBCONTRACTOR ______________________________ AREA OF W ORK ____________________________________

WORK STARTING DATE TIME W ORK ENDING DATE TIME
DESCRIPTION OF THE W ORK _________________________________________________________________________
Excavation by: HAND ____________________ EQUIPMENT ___________________ OTHER ______________
WORK EQUIPMENT _
SUBCONTRACTOR

Has the equipment to be: YES NO CHK OTHER: YES NO CHK

TO BE FILLED BY

Is the excavation more than 1.2m depth Is a Confined Space PTW required

Is shoring, benching or sloping required Are nearby structures (buildings, equip.)

that would affect the excavation
Are access ladders needed

Is road closure required Other special precautions to be taken:

SAFETY PRECAUTIONS
□ Watchman □ Flagman □ Safety Signs □ Warning Tape □ Permanent barricade
□ Spoil clearance □ PPE □ Others
FACILITY
In case of presence of underground facilities, hand excavation must be done to expose them and after a Site Survey shall
be done by Subcontractor and Contractor to ensure all necessary precautions are taken and eventually allow mechanical
excavation.
Are the underground pipes, cables, etc. in the area exposed? □ YES □ NO
TO BE FILLED BY CONTRACTOR

Are the underground pipes, cables, etc. within 15 m of existing facilities? □ YES □ NO

Civil Department Mechanical Department

Signature ___________________________ Date _________ Signature __________________________ Date _________
Electrical Department Instrument Department
Signature __________________________ Date _________ Signature ___________________________ Date _________
EHS Department Others
Signature __________________________ Date _________ Signature ___________________________ Date _________
Is the Banksman required full time during excavation? □ YES □ NO _____________
Are hard barricades required to protect excavation? □ YES □ NO
Is warning tape required to highlight excavation location □ YES □ NO ____________________________
Is the spoil to be immediately removed from the working area? □ YES □ NO ____________________________
Excavation by hand only? □ YES □ NO ____________________________
Is the Area to be screened by cable detector before the work? □ YES □ NO _____________________________

The Site has been checked and working Area accepted The Site has been checked and working Area accepted
APPROVAL

______________________________________
__________________________
SUPERINTENDENT CONSTRUCTION MANAGER OR DELEGATE