EXCAVATION WORK PERMIT

PTW Ref. No: Contractor:

Project Name: No. of Employees involved
Starting From Date Time Expected Completion Date Time
Activity:
Location of job to be performed:
Excavation Description:

Vehicles/ Equipment /Tools to be used:

Identify risk associated with this Excavation Work

Vehicle /Equip. Accidents Adverse Weather Inadequate Trench Support Electricution
Falling Debris/ Objects Man. Handling Injuries Falls/ Trips / Slips Faulty Tool/ Material
Noise Heat Vibration Confined Space
Other (Specify):
Precautions required to complete the work safely Yes No N/A
Have tools and devices to be used been tested and adjusted?
Warning Signs e.g. Warning Deep Excavation Installed?
Suitable Barricades installed around Excavation
Sufficient lightning provided?
Access and Egress Provided?
Personal Protective Equipment used properly?
Protection from Collapse planned – Shoring. / sloping / Benching?
Are permits associated require for this activity? if yes, mentioned below;
Hot Work Working at Height General Work Electrical Confined Space to Entry
Other (specify):

The following areas / items have been inspected by issuer and receiver
Access/Egress Danger/Warning Sign Lighting Safety Barriers
Hand Tools Other (specify)
PPE Required for the activity
Helmet Safety Shoes Safety Gloves Safety Ear Plugs/muff
Safety goggles Reflective Vest Dust Mask Safety clothes
Other (Specify):
Issue and acceptance before work
Acceptance of Work Permission by the person in-charge (Receiver)
I certify that, I have read and verified this work permit and checklist. I am aware of the risks that can be exposed to. I commit that I will be in line
with all safety rules mentioned in work permit checklist and will not deflect any of them.
Permit Receiver Name: Signature/Date:
Authority to proceed by authorized person (Issuer)
I reviewed the work permission checklist and checked the working conditions. I have reviewed all aspects of the task/activity and am satisfied
with the arrangements as detailed in the “risk assessment” have been put in place and certify that the activity detailed above is authorized to
proceed
Permit Issuer Name: Signature/Date:
Acknowledge by Contractor's Safety Engineer/Officer
I have reviewed the work permit, and verified entire checklist corresponding to workplace. All the necessary control measures have been taken
according to risk assessment and additional precautions are implemented.
Name: Signature/Date:
Clearance and cancellation after work or Suspension of permit
Clearance. (Site Manager)
All men, materials, tools equipment, housekeeping etc. under my charge have been withdrawn. The permitted work is complete / not complete.
Name: Signature/Date:
Suspension
This permit is suspended, I have notified the Authorized person specified that the work is not complete the area / equipment is not safe to use.
Name: Signature/Date:
 EXCAVATION WORK PERMIT
List of additional precaution measures required (SMEP`s Safety Officer/Engr. / Contractor's Safety Officer/Engr.)

1.

2.

3.

4.

5.

Permit Re-Validation

Sl. Receiver Contractor's

Date Time Issuer Signature Remarks
No Signature Safety Signature

This permit is valid for 7 days from the date of issue.