No.

00001
EXCAVATION AUTHORIZATION
Date of Issue: Time: Date of Expiry: Time:

WORK ORDER NO. WORK PERMIT TYPE HOT COLD

Unit/Operating Area:

Excavation Location:

Issuer Name: Signature

Description of Work:

ENGINEERING
ELECTRICAL ENGINEER

⃝ Has the Area been scanned? YES NO

⃝ Are there any underground cable? Electrical Telephone Instrument Cathodic Protection

YES NO YES NO YES NO YES NO

(If yes attach mark up drawing)

Manual Specify manual Excavation depths:……………..

⃝ Recommended means of Excavation:
Machine Specify machine Excavation depths:……………

Comments/Precautions:

Elect Eng. Name: Badge# Sign:

MECHANICAL ENGINEER

⃝ Are there any underground pipeline? YES NO (If yes, provide mark up drawings)

⃝ Are there any underground structure beams/obstacles? YES NO (If yes, provide mark up drawings)

⃝ Recommended means of Excavation: Manual Machine (Specify the depth)

Comments/Precautions:

Mech Eng. Name: Badge# Sign:

CIVIL ENGINEER

⃝ If 3 meters and above shoring plan with calculations attached? YES

⃝ If 6 meters and above shoring plan with calculations attached? YES

Civil Eng. Name: Badge# Sign:

MAINTENANCE SUPERVISOR OR PROJECT REPRESENTATIVE

AREA OWNER MANAGER/SUPERINTENDENT APPROVAL

⃝ Underground cables properly de-energized, Locked/Tag? YES NO (If yes, provide mark up drawings)
⃝ Underground pipeline isolated, depressurized, drained? YES NO (If yes, provide mark up drawings)
⃝ This Excavation Permit is valid for (1-30) days only Specify the duration of the Permit days

Manager/Superintendent Name: Signature: Date:

 No.00001
EXCAVATION AUTHORIZATION
Date of Issue: Time: Date of Expiry: Time:

WORK ORDER NO. WORK PERMIT TYPE HOT COLD

Unit/Operating Area:

Excavation Location:
Issuer Name: Signature

Description of Work:

ENGINEERING
ELECTRICAL ENGINEER
⃝ Has the Area been scanned? YES NO
⃝ Are there any underground cable? Electrical Telephone Instrument Cathodic Protection

YES NO YES NO YES NO YES NO

(If yes attach mark up drawing)

Manual Specify manual Excavation depths:……………..

⃝ Recommended means of Excavation:
Machine Specify machine Excavation depths:……………

Comments/Precautions:

Elect Eng. Name: Badge# Sign:

MECHANICAL ENGINEER
⃝ Are there any underground pipeline? YES NO (If yes, provide mark up drawings)
⃝ Are there any underground structure beams/obstacles? YES NO (If yes, provide mark up drawings)
⃝ Recommended means of Excavation: Manual Machine (Specify the depth)
Comments/Precautions:

Mech Eng. Name: Badge# Sign:

CIVIL ENGINEER
⃝ If 3 meters and above shoring plan with calculations attached? YES
⃝ If 6 meters and above shoring plan with calculations attached? YES

Civil Eng. Name: Badge# Sign:

MAINTENANCE SUPERVISOR OR PROJECT REPRESENTATIVE

AREA OWNER MANAGER/SUPERINTENDENT APPROVAL

⃝ Underground cables properly de-energized, Locked/Tag? YES NO (If yes, provide mark up drawings)
⃝ Underground pipeline isolated, depressurized, drained? YES NO (If yes, provide mark up drawings)
⃝ This Excavation Permit is valid for (1-30) days only Specify the duration of the Permit days

Manager/Superintendent Name: Signature: Date:

 EXCAVATION CHECKLIST BY OPERATION
YES NO N/A

Will Excavation impact other activities?

Is the area accessible in the event of Emergency?

Is the Excavation area marked out based on relevant drawing?

Has sufficient means of access/egress been provided?

Can Excavation be sloped to the required angle of 45 degree or benched?

Is shoring required?

Is the lighting in the area sufficient?

Does access to the Excavation require Confined Space Entry Permit (deep
more than 1.2 meter)?

Is soil be kept at a minimum of 1.2 meter from the edge of Excavation?

Has Security/Safety function been informed of road closure due to Excavation?

Has Security been informed if Excavation will take place within 15 meter from the
boundary fence?

Is the Permit valid and Permit conditions followed?

Are the protective system(shoring) intact?

Are tools/equipment in good condition?

Are barricades & sign boards available and in place?

Are walkways/bridges in good condition if( provided )?

Are lighting lights provided for visibility in the dark(if required)?

Is machine excavation to be used?

Is a flagman required?

Dewatering equipment required?

Have all personnel been made aware of underground locations, permit conditions and any
other hazards relevant to the task?

WORK COMPLETION

Maint/Project Acceptance of Work

Completion
Name: Sign: Date:

Operation Acceptance of Work

Completion
Name: Sign: Date: