WORK PERMIT EXCAVATION, BACK FILLING & SURFACE DRESSING

Project: _______________________________________ Date of Work: ___________________________________________

Name of the Contractor __________________________ Type of Excavation: Trench/Mass/Footing/Pile/Other ____________

Activity time from to ____________________ Excavation Size: _(L X B X W)______________________________

Location/Area of Work: ___________________________ JSA No: _______________________________________________

Preparation for Works: (Tick)

Sl. No Description Yes NA

1. Is proper marking for the proposed excavation done?
2. Is the Work method statement and JSA approved and Understood by Supervisor?
3. Are the Involved machineries, Vehicles & tools properly checked prior to use?
4. Is the sufficient barricading material, warning sign available prior start of excavation?
5. Is underground service clearance (1st time, brown field project) taken from FCM team?
6. Layout plans with clearly marking UG services shown, understood, and signed by FCM, PMC & Contractor
team?

CIVIL Electrical Mechanical

(Pipe (Underground HT/LT cables) (Gas lines, water lines etc.)
lines/Drains/Manholes/Sewage/Tra
de waste)
Bosch FCM / Bosch FCM / User* Vendor Bosch FCM /
Vendor PMC User* Vendor PMC As Applicable PMC User*
As Applicable As Applicable

*As applicable – Only for initial clearance and clearance drawing / sketch.
Underground Service Clearance-(Write Precautions)
___________________________________________________________________________________________________________

__________________________________________________________________________________________ (Contractor/PMC)

The below signing person will be responsible to ensure that the above described work will be done under all the safety Precautions mentioned
on the permit and job safety analysis as required by the project.

Permit requesting by Contractor Permit approved by-PMC Permit Closing Details

Sign Sign Sign
Sign Sign Sign Sign
Time Time Time
Time Time Time Time

Site Engineer HSE – S/C Site Engineer PMC - HSE Site Eng. S/C HSE – S/C PMC - HSE

Permit Close Details:

1. Excavated area is hard barricaded with appropriate sign board.

2. Adequate slope/benching has been done for excavated area.
3. Excavated earth removed and stacked outside working area at a designated place
4. Access and aggress for the excavation is made available

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