Excavation Work

MML4-CA08-RIFAST-HMS-GNS-5008 Rev.:03

Project Name:

Location: Date:

Sub-Contractor: Permit No.

Precise location of Excavation work: PERMIT VALIDITY (Max. 12 hrs)

From To
Excavation work activity: Date
Time
Safe System: A suitable and sufficient safe system of work must be available for this activity. Essential checkpoints are
as below:
S.
Condition Yes/No NA Comments
No
1 Risk Assessment available
2 Tool box talk performed, attendance recorded
Is permission for excavation obtained from authorized
3
department
4 Is excavation upto 1.5m done by manual only
5 Excavation is of manual or mechanical type
Any structure nearby excavation get affected due to
6
excavation
Area cordoned off and precautionary sign board of deep
7
excavation displayed prominently
Proper means of escape / exit available. If ladders are used,
8
the minimum length of ladder is (1.1 X H + 1) m.
Excavation may cause traffic hindrance. Is traffic control co-
9
ordinated.
Can excavation affect adjacent property? Adequate
10
preventive measures taken?
Underground utilities life Optic Fiber Cables / Power Cables /
11
Pipes (Water / Sewage / Oil / Gas) identified
The trenches / pits are adequately shored / timbered in non-
12
cohesive soils excavation.
13 Area fenced / barricaded
Heavy equipment restricted to minimum distance equivalent
14
to depth of trench / pit.
Persons are trained / experienced to perform excavation
15
work activity
16 Electrical and mechanical equipment involved or isolated
17 Adequate lighting provided during night shift
18 Is operator is competent for excavation work
19 Does banks man available
20 All hand tools are insulated with non conductive material
21 Daily checklist or machinery maintained
22 Does competent supervisor available for the job
23 Is appropriate PPE provided for worker
Legend: Yes – “”, No – “”, NA – Not Applicable

REVIEW AND CHECKED BY:

STAGE-1:- APPLICATION BY JOB SUPERVISOR/SITE ENGINEER

I have checked and confirmed that the above safety requirements have been complied with:-
Name:- ______________________________ Designation:__________________________
Company:_________________________________________________________________
Date:___________________ Time:__________ Signature:___________________________
 Excavation Work
MML4-CA08-RIFAST-HMS-GNS-5008 Rev.:03

Project Name:

Location: Date:

Sub-Contractor: Permit No.

STAGE-2:- APPROVAL BY SITE INCHAEGE

Actual site condition sketch has been prepared and attached. Based on that I am fully satisfied that all safety measures have been
implemented and enforced.
Name:________________________________ Designation:___________________________
Date:____________________ Time:_________ Signature:_____________________________

STAGE-3:- INSPECTION BY SHE PERSONAL

I have inspected the above-stated location and confirmed that the recommended safety measures are in place and the said lifting plan is
safe for work at the point of inspection.
Name:_______________________________ Designation:__________________________
Date:___________________ Time:_________ Signature:___________________________

STAGE-4: CANCELLATION

I declare the all lifting work under my control has now been stopped and all tools and other equipment’s have been removed.
Name:________________________________ Designation:______________________
Date: __________________ Time:___________ Signature:________________________

STAGE – 5: PERMIT CLOSURE

We have inspected the above-stated location and confirmed that the recommended safety measures required to close this permit have
been done.
Name:_______________________________ Designation:__________________________
Date:___________________ Time:_________ Signature:____________________________