EXCAVATION WORK PERMIT

Area to be provided with suitable acess and egress Underground survey for un-identified objects in place Machine guarding and toolbox talk to be in place

During work Area is isolated by barriers and signs Suitable PPEs for all personnel
JSA strickly followed Safe load working for all equipment to be followed Bankman is provided at all time
Permit Registry No.
Traffic prevention procedure in place at all time Soil survey and slope checked by competent persons Stop work if unexpected condition found
THIS PERMIT IS AUTOMATICALLY SUSPENDED UPON ACTUATION OF THE GENERAL ALARM
After work The trench area to be left clean and safe secure conditions Plant/equipment to be removed to safe parking area
AND MUST BE RETURNED TO THE PTW OFFICE FOR RE-ISSUE BEFORE RESTARTING WORK
Others :
1. SPECIFICATION OF WORK
5. PERSONAL(PERSONNEL) PROTECTIVE EQUIPMENT & SAFETY EQUIPMENT REQUIRED
Work Location : System (Item NO.) :
Eye protection Face shield Full chemical suit Fire Blanket Safety harness Eye Wash Station
Work Description :
Hearing protection Dust mask Paper Coveralls Inertial reels Work lifevest Radio
Head protection Foot protection Fire Extinguisher Life Line Escape (BA) Set Rubber Boots
Reason for excavation / piling :
Rigger Gloves Personnel Gas Detector Industrial Gloves Welding shield Tripod OSR Equipment
Nearest Unit No. / Structure :
Cold Weather Clothing Ice and Snow Traction Fire Retardant Clothing Emergency Shower Fresh air mask Full/hair face gas mask
Size of excavation : Length - Mts. Breadth - Mts. Depth - Mts.
Gas Detection : O2 CH4 H2S CO Other :
Equipment & Tools to be used : Hand tools Excavator Trucks Compressor Vibrator
Others :
Elec. tools Bulldozer Others :
6. GAS ANALYSES OR INITIAL GAS TEST(Authorized Gas Tester)
Dewatering system required : Yes No
Details Date Authorized Gas Tester
Validity : This Permit is valid from DATE Hrs to DATE Hrs
8 hourly Time Name
Requested by : Signed : ※ Task must be clearly described. 4 hourly Combustible (%) Initials
Continuous Toxic/H2S Date
3. SAFETY CHECK
Other : Oxygen (%) Time
A. CIVIL / MECHANICAL SECTION ※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. ※ Usable O2 CH4 H2S
※ Comments/Remarks : other sheet CO Other
Area free including telephone cables : Yes No Area free including Pipelines / Drains : Yes No
7. APPROVAL & ISSUE
Depth of cable, if knows : Mts. Depth of Pipeline / Drain, if knows : Mts.
Step1. Reviewed by ( Contractor Engineer )
Safety checks YES NO Safety checks YES NO Safety checks YES NO
Date : Time : Name : Signed :
Shoring required Hazard indicating light required Concrete paved area
Comments :
Area barricading required Road block required
Step2. Reviewed by ( HSE Authorized representative )
Special instructions, If any :
Date : Time : Name : Signed :
Comments :
B. ELECTRICAL SECTION
Step3. Approved by ( Construction Authorized representative )
Area free including telephone cables : Yes No Type of cable : HV MV LV NA
Date : Time : Name : Signed :
Depth of cable, if knows : Mts. Others : Comments :
Step4. Accepted by (Subcontractor Task Supervisor / Site Manager)
Safety checks YES NO Safety checks YES NO Safety checks YES NO
Power cable present in the area Protection for existing cables required Hand digging allowed I have read and understand the above conditions and precautions and declare that I accept responsibility for
Electrical isolation required Mechanical digging allowed carrying out work specified on this Permit, that no attempt will be made by myself or by the persons under my control to
Special instructions, If any : carry out any other work, and that I will notify the Contractor engineer(HEC) upon completion/suspension of this work.

Date : Time : Name : Signed :

C. HSE(SAFETY) DEPARTMENT CHECKS
8. RE-VALIDATION ( Compulsory RE-VALIDATION of the work permit each shift - to Continue work )
Road Closure : Yes No If yes - Give full details :
Subcontractor HEC HEC - HSE Subcontractor HEC HEC - HSE
Date Validity Time Date Validity Time
(Task Supervisor) Site in-charge (Coordinator) (Task Supervisor) Site in-charge (Coordinator)
Safety Equipment : Road Signs Barriers Flashing Lights Traffic Lights
Other Instructions :

3. HAZARDS IDENTIFIED Signature Signature Signature Signature Signature Signature

Overhead Power line Overloading Equipment Deep excavation(>2m) Soft / Wet ground
Limit of access Moving Machinery Confined Space Tripping Hazard Signature Signature Signature Signature Signature Signature
9. PERMIT CLOSE-OUT ( CLOSURE )
Collapse Water accummulation Underground facilities is hidden Unknown ground conditions
Closed by(Subcontractor) Accepted by (HEC CM) Registered by (Permit Coordinator/HEC HSE)
Bad weather affected Nightshift
Date Time Date Time Date Time
Others : Signed Signed Signed

4. PRECAUTION TO BE TAKEN
Cross-Referenced Documents : YES NO
Before starting Drawings, Method statement has been approved Barriers and signs to be in place ※ NOTE
Attached File : YES NO