EXCAVATION / ROAD CUTTING PERMIT
Format No : HSE – 10 Rev 0
Contractor: M/s …………………………………………………………………………….
Location …………………………………………………………………………………. …………………………………………………………………… ( Enclose sketch ) Description of work : …………………………………………………………………….
Method of Excavation: Manual / Mechanical
Permission is solicited from :………………………( Date )………………………..….hrs. To : ………………………( Date ) …………………………....hrs.
Site Engineer (Initiated By) Sig. of Safety Officer (Checked By) Sig. of Eng.-In-Charge(RCM) Name …………………….. Name …………………….. Name …………………….. Signature…………………… Signature…………………… Signature…………………… Safety checks for Road Cutting/ Excavation work Existing Not Existing Precautions Underground Telecommunication line Underground Electrical Cable Underground Sewer / drinking water line Underground Fire water line Underground Product / Utility line
Excavation is provided with hard barricade : YES / NO Excavation is provided with Ramp / Steps : YES / NO
Permission is granted for the above mentioned job. Permit will ensure that all precaution stated above are observed.
Permission is solicited from :………………………( Date )…………………………..hrs. To : ………………………….( Date ) ……………….…….…..hrs.
Elect. Co-ordinator, EIL Area .Co-ordinator, EIL Safety Deptt. EIL Name ……………….. Name …………… Name …………… Signature……………. Signature…………… Signature…………… Main Contractor’s site engineer shall abide by the precautions / conditions stated all over)
Note : - Permit to observe precautions as mentioned above. - Barricading with tape/ hard barricading should be done on all said of excavation. - Excavation & Road Work Procedure as per OISD-192 must be followed. - Permit must be available at the site of work.
GRANT OF PERMIT AND EXTENSIONS
Extension Period Work Time Sl. Contractor Site Site Engineer From ______From: Hrs No. Engineer (PMC) To______To: Hrs
01
02
03
04
05
06
07 EXCAVATION WORK PERMIT
PROJECT : SITE : DATE : Work Time : From ______Hrs. To ______Hrs : EXACT LOCATION OF EXCAVATION :
Format no.: /HSE/
1) Type of Job :-
2) Depth of Excavation: 3) Excavation as per Drawing. :…………………….. YES / NO 4) Excavation provided with slop:………………….. YES / NO 5) Excavation is near to Drain / CSS :……………….. YES / NO 6) Excavation is provided with hard barricade:…….. YES / NO 7) Excavation is provided with Ramp / Steps:……… YES / NO 8) Tool box talk introduced: YES / NO 9) Precaution taken for heavy vehicle. a) Warning sign board:…………………………… YES / NO b) Back stops on rear wheel:……………………... YES / NO c) Vehicle with reverse alarm:……………………. YES / NO
10) Persons working at work place with PPE:…….. YES / NO 11) Ensure Manual Excavation upto 1.5 M resorting to mechanical Excavation Sig. of Site Engineer/Eng.-In-Charge Sig. of Safety Officer
(Initiated By) (Checked By)
Permission is granted to work : Yes / No
EIL (Electrical) EIL (Safety)
GRANT OF PERMIT AND EXTENSIONS
Sig. of Safety Work Time Sig. of Site Verification Validity Period Officer Sl From _____ Engineer/Eng.- by EIL From______Checked By No. Hrs. In-Charge of (Electrical) To ______(Safety Officer) To ______Hrs Contractor with date of Contractor
Additional safety instructions, if any:-