Appendix-2b

REV 5
EXCAVATION WORK PERMIT (PTW-Excav)
Project J101

Instruction : To apply on or before the day of Start Work

Serial No :
CONTRACTOR COMPANY
DESCRIPTION OF WORK
LOCATION OF WORK (Attach a sketch)

DATE FROM TO LOCATION

SPECIAL MEASURES TO BE TAKEN ;

(f) Shoring & bracing for excavation / trench / pit
(a) Have valid DCE from relevant utility agency  depth > 1.5m but < 4m 
(g) Shoring & bracing for excavation / trench / pit in
(b) Permit to Dig approval from LTA  accordance to PE design for dept >4m 
(c) Excavator operator is registered with PUB has (h) Personnel involved briefed on the RA & SWP
conducted  and utilities location 
(i)Excavator is in good working condition and
(d) Trial holes carried out in accordance to requirements  operated by competent operator 
(e ) Safe means of access provided for excavation / trench / (J) Banksman is deployed with whistle and briefied
 on all safety requirements 
(f) Open excavation / trench / pit barricaded for depth > (k) Changing ground conditions has been verified ,
1.5m  particularly after rain 
Others ; Appointed Banksman:

Items not required to indicate -NA Name and signature :

PART A - PERMIT REQUESTER : (Applicant - Site Supervisor-in-charge)
I certify that I am competent to carry out the Person-In-Charge function and fully understand the documentation associated with the task. I am
satisfied that the personnel who will be deployed on the task are competent, properly equipped and fully understand the risk assessment. I
understand all the safety precautions to be taken under client's requirements & current legislations and i have prepared the above-mentioned
area to be safe for the task.

Name & Signature ________________________ Position, Date & Time: ____________________

PART B - SAFETY CHECKER : (Appointed Sub-contractor Personnel)
I have assessed / inspected together with the applicant for the above-stated location and confirmed that the recommended safety measures are
in place and the said location is safe for work.

Name & Signature ________________________ Position, Date & Time: ____________________

PART C - SAFETY ASSESSOR : (Appointed CR11 Personnel)
I have assessed / inspected together with the appointed sub-contractor safety checker to verify that the recommended safety measures are in
place and cerified the above-stated location for the activity / process is safe to proceed.

Name & Signature ________________________ Position, Date & Time: ____________________

Part D - ACKNOWLEDGED BY : (CR11 Safety Personnel)
I have acknowledged that this permit-to work is being applied and I will do my due digilence to check and inspect the work activity periodically to
ensure it is safe throughout the whole duration of the applied permit.

Name & Signature ________________________ Position, Date & Time: ____________________

Part E - PERMIT APPROVED BY : (CR11 Project Manager / Deputy Project Manager / Construction Manager)
I am satisfied that all safety requirements are in place. Permission is hereby granted to the applicant of this permit to carry out the above-
mentioned activity(ies) at the above-mentioned area(s).

Name : ________________________________ Position : ____________________

Signature : ________________________________ Date & Time : ____________________

Permit issued to be kept by

excavator operator: ___________________________ _____________
Name / Signature Date / Time
PART F - Notification of Work Completion / Cessation of Work ( Please tick One)
 I confirm that the above-stated work was completed safely on at hours

 The above-stated work was stopped on at hours due to unsafe conditions

Name & Signature ________________________ Position, Date & Time: ____________________

THIS PERMIT MUST BE DISPLAYED PROMINENTLY AT THE WORK AREA
Excavation PTW_V5_31032023