PERMIT TO DIG A (3) 1.

018
This permit only applies to the work specified below,
and is only valid for the period of issue stated

PERSON COMPLETING
DATE:
PERMIT:
SITE LOCATION:

DETAILS AND EXTENT OF WORK:

Services Locations and drawings

Checked Attached Marked on Site
Water
Gas
BT
Electricity <415v
Electricity 415v – 11Kv
Electricity > 11Kv
Other
Total number of drawings attached

Actions to be adopted (Person approving permit delete as appropriate) Required

1 CAT survey prior AND during excavation work
2 Hand digging trials prior to excavation
3 Hand excavation only where services are marked or believed to be in existence
4 Use of spotter at point of excavation
5 Supervisor/Site Manager checks during excavation
6 Shoring/propping of excavation
7 Other (Details):

PERMIT VALID DATE PERMIT VALID TIMES

 Details of restrictions relating to permit (To be identified before issuing)

All available drawings have been checked, statutory undertakers contacted and all services are
marked or staked out.

I have checked the intent of this permit and am of the opinion that all know information has been
checked/consulted and that the area is marked and ready for excavation.

Signature of Person Name of Person

Issuing Permit Issuing Permit
SIGNATURE OF PERSON NAME OF PERSON IN
IN CHARGE OF WORK CHARGE OF WORK

I certified that this permit to work is cancelled and that the task/activity detailed above has
been:- (* delete as applicable)

*a. Completed at___:___hrs on the______ (date).

*b. Stopped/Suspended. I concur that the task was stopped/suspended for the reasons
detailed below and arrangements have been put in place to prevent unauthorised
access.

The task detailed above has been stopped/suspended for the reasons detailed:

The following arrangements are in place to prevent unauthorised access to the work area:
Signature of Person Name of Person
Cancelling Permit Cancelling Permit