Excava on Work Permit PTW/EWP/_____________

SecƟon 1: Work Details

General PTW Serial No.: Work Loca on:
Work to be done:

Working Date: From: Un l:

SecƟon 2: Safety Checklist

ExcavaƟon work permit expires at the end of work shiŌ day. Please review the excava on work permit DAILY by going through
the Safety Checklist below and approved the renewal in Sec on 3.
Remarks: (√: DONE) (X: NOT DONE) (NA: Not Applicable)
No. Items
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Design and method of excava on
1
approved
Adjacent areas and protec ve systems
2
are inspected?
Protec on arrangements done on loose
3
rock/soil that could pose a hazard?
Materials, and equipment set back at a
4
safe distance from the edge?
Physical barriers provided at all located
5
excava ons, wells, pits, sha s, etc.?
U lity companies contacted and exact
6
loca on of u li es line are marked?
Energized electrical systems (at
7 underground and overhead) are de-
energized and lock out?
Surface water or runoff diverted or
8 controlled to prevent accumula on in
the excava on?
Inspec on is made a er every rainstorm
9
or other hazard increasing occurrence?
Confined space entry permit is applied?
10
(If required)
Working at Height permit is applied? (If
11
required)
Permit Applicant (Signature):
Permit Applicant (Name):
Date:

SecƟon 3: Permit Review & Approval

I have personally verified the condi ons necessary and as specified I authorized this excava on work to begin.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Permit Issuer (Signature):

Permit Issuer (Name):

Designa on:
Date:
Time:

SecƟon 4: ExcavaƟon Work Permit Closure

I have personally checked the condi ons necessary. Any con nua on of work for next day require comple on of Sec on 2: Safety Checklist
and approval from Permit Issuer.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Permit Issuer (Signature):

Permit Issuer (Name):

Designa on:
Date:
Time: