Contract No. & Site:
Contractor:
Competent Person supervising the works. / Name: / Position:
Excavation location(s) and specification
Soil Type(s)
Plan or sketch of existing services enclosed - record original drawing no: / YES / DWG/No.
HAZARDS
There exists the potential for the following hazards to be present:
LV/HV Electricity / Yes/No / Hazardous soils/substances / Yes/No
Gas/pressurised services / Yes/No / Underground structures / Yes/No
Piped water / Yes/No / Explosive ordnance / Yes/No
Telecomm/ fibre optic / Yes/No / Piped fuel/petrochemical / Yes/No
Sewage pipes / Yes/No / Ground/surface water / Yes/No
METHOD STATEMENT AND RISK ASSESSMENTS AND CONTROL MEASURES
A Method statement and Risk assessments has been approved for this activity( Number):
The excavation has been assessed and the following control measures are to be implemented. Note: CAT scan and hand dig MUST always be completed and then additional control measures agreed
Locate hazards by hand digging/Cable Avoidance Tool (CAT) survey / Yes/No / Piles covers to be installed upon completion / Yes/No
Continued gas monitoring - record unit type/serial no: / Yes/No / Safe access and egress / Yes/No
Use of any powered plant or tools, PROHIBITED within 500mm of services / Yes/No / Weils diseases tool box talk given / Yes/No
First aid/emergency procedures available/ No smoking in excavation / Yes/No / Provide temporary support to services / Yes/No
Relevant Echo AP / Facilities AP consulted (Gas, Electricity, Pressure systems / Yes/No / Pre-task briefing completed including emergency procedures and F-Aid / Yes/No
SECTION 2: AUTHORISATION (Site Manager’s authorised person)
Approval of permit, and authorisation for works to commence.
Name: / Position:
Signature: / Valid from Date: / Valid to Date:
SECTION 3: ACCEPTANCE OF PERMIT (Trade Contractor’s competent person to complete)
Verification of Checklist, Method Statement & permit, authorisation for issue.
Name: / Position:
Signature: / Date:
SECTION 4: Completion of work (Trade Contractor’s competent person to complete).
The work for which this Permit was issued is complete and all persons, materials and equipment under my supervision have been withdrawn.
Name: / Position:
Signature: / Date:
SECTION 5: CANCELLATION (Appointed by Site Managerpermit to work competent person)
The cancellation of this permit precludes any further excavation taking place in this location.
The excavation(s) covered by this permit, have been left in a safe manner: / Backfilled Protected
Signature / Date: / Time:
Attachments:
Method Statement:
/No
/Method Statements No:
/MS
Extensions :Extension 1 / Extension 2 / Extension 3 / Extension 4
New Completion Date:
AP Signature :