EXCAVATION PERMIT

Request Location:
Permit No:
Scope of work: Max Depth:

Valid from: (Time) Date:

Valid to: (Time) Date:

Supervisor in Charge Name and Number:

Approvals for Work to Proceed

Restrictions: Specify controls below:

Area Surveyed*
Y/N
(Visual Assess / Radar)
Services Identified & Marked Y/N
Hand Dig only Y/N
Confined Space Y/N

Other Issues Specify controls below:

Traffic Management Y/N

Backfill Movement & Storage Y/N
Other (Specify) Y/N

Acceptance
Issued by : Date:
Received by : Date:

**Permit Issuer to ensure Supervisor & Method Statement in place to control works.

Close Out
Completed/ Stopped Name: Time/ Date: Permit Receiver

Permit Cancelled Name: Time/ Date: Permit Issuer

You must gain another permit for any other day(s) other than approved days noted in Section 1.