CLIANT:

CONSULTANT: EXCAVATION WORK PERMIT Permit No.

SECTION A: Application for excavation works (To be completed by Permit Receiver)

Plant Area/Location Date:
Excavation Period:
Start: Completion:
Name of Contractor/Sub Contractor No.of Workmen Mechanical Excavation Hand Excavation
Length: Width: Depth:
Description of the job:

JSA Number JSA attached with permit?

SECTION B: Review of underground services (To be completed by Technical Department/Civil/Electrical/Mechanical) if applicable

Review of the underground services drawings indicate the following:
No underground services on this area Underground services are indicated on the drawings (See detail below)
Description of the underground service Operating Pressure/ Voltage Depth at which service is buried

Drawings reviewed by: Date: Signature:

Civil Department
Electrical Department
Mechanical Department
SECTION C: Description of hazards related to the excavation work (To be completed by Issuing Authority)
Power Cables Process Piping Communication Cable
Equipment/Foundation undermining Cave-in potential Flammable/toxic vapors
Vehicular traffic Noise
Sewer/drainage pipe work vibration affecting excavation
Others: (Specify)

SECTION D: Precaution to be taken during excavation (To be verified by Site Engineer/Supervisor)

Cave-in precaution using: Shoring Trench shield Sloping Benching
Is proper Ladder/access provided for safe
access/egress of man and equipment with Yes No N/A
proper railing?
Other:
Heavy vehicle movement restricted to come
within 1 m of the edge of the excavation Yes No N/A
Physical barricades
Stand by man required at noisy area: Yes No N/A Banks man
located underground services. Yes No N/A Notify other groups
Access of persons restricted within radious Additional lighting
of the excavator Yes No N/A
PPE
Electrical services are de-energized: Yes No N/A Toolbox talk to be completed
Excavated earth to be placed or placed at 1
Yes No Warning Sign
meter from the edge of the trench
Dewatering arrangements done? Yes No N/A
SECTION E: Safety Talk & JSA Communication ( Site Engineer/ supervisor shall sign the permit before start the work
after on site safety talk,JSA communication and verification of site safe for job execution)
Safety Talk & JSA Communication Done? Yes No Communication done by :
Signature :
Additional Control measures if any :

SECTION F: Gas Testing (if applicable)

Frequency:- Once Continuous Hourly N/A
Date Time Name Signature O2% LEL% H2S (ppm) Other

SECTION G: Validation and Issue of permit

I have read, understand & reviewed the hazards and precautions to be taken during the excavation detailed above.
Issuing Authority (NCC PM/ Manager) EHS Manager/Officer
Name: Name:
Sign: Sign:

Site Engineer / Supervisor

Name:
Sign:

SECTION H: Work Completion/Permit Closure (To be completed by Permit Acceptor & Site Engineer)
Work Completed Work is incomplete Area is Safe, Clean & Physical barricades provided
Site Engineer name : Permit Acceptor name:
Sign Date Sign Date

Permit Renewal
Day.2 Date : Start Time: End Time:
Issuing Authority(NCC PM/ Manager) Site Engineer EHS Manager/Officer

Name:

Signature:

Day.3 Date : Start Time: End Time:

Issuing Authority(NCC PM/ Managers) Site Engineer EHS Manager/Officer

Name:

Signature:

Day.4 Date : Start Time: End Time:

Issuing Authority(NCC PM/ Manager) Site Engineer EHS Manager/Officer

Name:

Signature:

Day.5 Date : Start Time: End Time:

Issuing Authority(NCC PM/ Manager) Site Engineer EHS Manager/Officer

Name:

Signature:

Day.6 Date : Start Time: End Time:

Issuing Authority(NCC PM/ Manager) Site Engineer EHS Manager/Officer

Name:

Signature:

Day.7 Date : Start Time: End Time:

Issuing Authority(NCC PM/ Manager) Site Engineer EHS Manager/Officer

Name:

Signature:

Definition Excavation
An excavation is any man-made cut, trench or depression in the earth’s surface as formed by earth removal. (This can include anything
from building foundations to a new road to an excavation for a new pipeline, or piling works)

Specific Requirements for excavation deeper than 1.2 meter

When the excavation is near pipelines or near hazardous substance storage, monitor the LEL-level and level of corrosive or toxic
substances in the ditch, because most of the vapors of these products are heavier than air and will concentrate in the ditch.

When cranes, vehicles, etc. are operating near the excavation, verify if it is possible that a reasonable concentration of carbon monoxide
(CO) from the vehicle’s exhaust can enter the ditch or excavation. (Site specific)

Verify if necessary measures are taken to prevent water accumulation in the ditch or excavation. If equipment is used to avoid water
accumulation, it needs to be operated by an experienced person.

GENERAL INSTRUCTIONS FOR EXCAVATION

Any excavation performed  regardless size of excavation by hand or any type of machine or equipment will require an excavation permit
prior to beginning any dig.
Excavation permit is valid for one week and only for the specific location and time period including depth indicated on the permit. Next week
new permit to be taken .

The excavation permit shall remain at the site of excavation during the entire time the excavation is being accomplished.

Excavation shall be evaluated for horizontal in addition to cave in potential. Electrical sources, energized (pressurized) pipes,
underground tanks, etc. may present a hazard to employees who are required to enter the excavation area.

Water shall not be allowed to accumulate in excavation areas at any time, Pumps, drains, or other means shall be used to remove water
continually from the excavated areas.

Where any equipment (i.e. power shovel, digger, rock breaker, etc.) is working around, or in an excavation, no person shall
be permitted to work in the excavations within 5m of the machine, or within 3m of the maximum reach of the machine. Where
personnel are required to hand trim excavations within 5m of the machine, it shall be stopped from operating until the hand
trimming is complete
Mechanical excavation is not to be carried out 5M near to the energized existing services
Site supervision to be available at all times at site