Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1

Form Permit to Excavate Date:

Reason for excavation:
PERMIT NUMBER: LOCATION:

Section – I CONTACT DETAILS

Permit Issued By (MAK Engineer- Contact Number
Authorized Party)
MAK Task Supervisor/Foreman /
Contact Number
Subcontractor (Permit Receiver)

Section – II PERMIT VALIDATIONS

PERMIT ISSUE DETAILS Date ____________________ Time ___________ CONDITIONAL EXTENSION
WILL BE GIVEN ON THIS
PERMIT EXPIRY DETAILS Date ____________________ Time ____________ PERMIT
THIS PERMIT IS ONLY TO BE USED BY THE PERSONS TO WHOM IT IS ISSUED. ON COMPLETION OF THE TASK OR ON EXPIRY THE
PERMIT IS TO BE RETURNED TO THE ISSUER FOR CANCELATION
(Work may not commence if one of the following is not complied
Section – III PREREQUISITE with)

 for YES and X for No Yes N/A  for YES and X for No Yes N/A
Is the Work Area Clearly Defined? Have the Has the Excavator been inspected and
1 13
Latest work drawings been Consulted? passed as fit to work?
Is a NOC in place to allow excavation to be Has the operator a valid licence to
2 14
carried out? operate machine?
Does the operator hold the
Has the position of the excavation been
3 15 competency certificate to operate the
plotted on site plan and agreed?
machine?
Has the Area been Scanned for Services with Arrangements for Hard Barriers and
4 CAT Scanner and CAT Scan competent 16 warning lights are available in
person sign in the highlighted drawing? excavation area?
Has a Risk Assessment Been
5 Are All Service Locations Clearly Marked? 17
Completed for the task?
Is the excavation to be carried out
6 18 Appropriate signage’s are in place?
mechanically (using equipment / excavator)?
Arrangement for Illumination provided
19
Have All necessary Trial Pits been excavated for night?
7
before actual excavation? Other (including Structures, Shoring/
20
Benches/Slope) planned?
Is there an arrangement to remove the
Has the daily excavation checklist been excavated spoil and kept at a suitable
8 21
attached with this permit? distance away from the edge of the
excavation?
If adequate sloping /benching/stepping
Has the excavation been clearly signed to is not possible, is there an
9 warn those working around the area? i.e. 22 arrangement to the use of trench
"Warning- Deep Excavation" boxes used to protect workers from
collapse?
Has sufficient access arrangement
Have suitable barricades been installed been provided to /from the
10 around the excavation? i.e. physical barriers 23 excavation? i.e. access through
for vehicles; soft barriers for pedestrians barricades; access points every 8m
within excavation?
Are all barricades kept at least 1.8m away
11 24 Others (If Any)?
from the edge of the excavation?

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 Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1

Comments:

Note: - If more space is required please attached additional sheets and/or pictures.
DECLARATION BY THE PERMIT APPROVER (AP) DECLARATION BY THE PERMIT RECEIVER

I _________________ representing MAK, hereby I ________________________ representing _________________

declares that after checking the work location, providing the identified hereby declare that I will fulfil above mentioned all requirement
resources, works and emergency procedures - being briefed to the team, prior to the excavation and follow the safe work procedure
hereby Approves the works to proceed.

Date: ……/……/…… Name; ……………………. Signature………. Date: ……/……/…… Name; ……………. Signature…….…

SECTION IV PERMIT CONTROLLER AND VERIFIER

Work shall be carried out ONLY after complying with the precautions given in Section – III of this Permit.
The permit is valid up to hrs. on __ It has to be ensured that the employee executing the Job has a copy of this
permit and CAT scanning report at all times during work. All equipment must be suitable to the task, taking into account the
control measures for the risk due to the hazards must be within acceptable level. Before closing the PTW, area has to be
rendered harmless.

Name of Safety Officer: ______________________________ Date:/……/……. Time: ………… Signature…………….

Note: - The Permit validly is for seven (07) days, subjected to be attached with daily excavation checklist signed and verified by
Site Supervisor / Engineer.
PERMIT EXTENSION (SUBJECT TO DAILY EXCAVATION CHECK AND COMPLETION OF THE WORK)
Permit Closed (Day 1): Date: _________________ Time: _______________
Permit Extended (Day 1) Date: _________________ Time:_______________
Permit Closed (Day 2): Date: _________________ Time: _______________
Permit Extended (Day 2) Date: _________________ Time:_______________
Permit Closed (Day 3): Date: _________________ Time: _______________
Permit Extended (Day 3) Date: _________________ Time:_______________
Permit Closed (Day 4): Date: _________________ Time: _______________
Permit Extended (Day 4) Date: _________________ Time:_______________
Permit Closed (Day 5): Date: _________________ Time: _______________
Permit Extended (Day 5) Date: _________________ Time:_______________
Permit Closed (Day 6): Date: _________________ Time: _______________
Permit Extended (Day 6) Date: _________________ Time:_______________
Permit Closed (Day 7): Date: _________________ Time: _______________
Permit can not be extended further.
PERMIT CLOSED: The Excavation is Completed / Permit ended /
Other reason and the area is safely secured (Permit Receiver) Date: ……/……/……. Time: ………… Signature…………….
PERMIT CLOSED: The Excavation is Completed / Permit ended /
Other reason and the area is safely secured (Permit Issuer) Date: ……/……/…… Name; ……………. Signature...………

PERMIT COPY
Project Manager (PM) Construction Manager/ PE Supervisor (Work location) HSSE
DISTRIBUTION:

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 Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1

PRE-EXCAVATION UNDERGROUND SERVICES DETECTION CHECK RECORD

Section 1

Authority NOC Ref: -

Method Statement Ref: -

CAT Scan carried out for the excavation (Drawing Attached): -

Name of the Engineer: - Date & Time: -

Location: -

Signature: -

Note: - All CAT Scan locations and drawings shall be marked against the auditable alarm during CAT Scanning.

Section 2

Drawing Ref. Received from MAK Technical Section

Comparison with the filled CAT Scan Report

Attach Underground Utility Drawing Ref: -

Location: - Date & Time: -

Name: - Signature: -

Section 3

YES NO
Trail Trenches initiated as per underground Utility
Drawing and per CAT Scan Report.
Incase of NO, Please state the reason for not carrying out.

Location: - Date & Time: -

Name: - Signature: -

Note: - This form should be attached with Drawings / Reports of CAT Scanning & Underground Services, received
from the technical section. Excavation Permit page 1 and 2 only to be filled after completing this section above
(Page 3).

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 Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1

Daily Excavation Checklist Date of Inspection:

Permit Extension Day: Excavation Permit Number:

S. No. Items YES NO N/A Remarks

Has the excavation permit been obtained, correctly completed,
1.
and displayed at site?
2. Are the underground services isolated if required?
Does the permit specify any special hazards and appropriate
3.
controls thereof?
If YES in No.3; Are the controls known and being implemented by
4.
the workers?
Is the method of excavation, stated in the permit and approved
5.
Method statement being followed?
Is the excavation shored, sloped, or shielded adequately during all
6.
stages?
Are there signs of water seepage? If so, is a de-watering system
7.
in place?
Have excavations deeper than 1.2m been designed to prevent
8.
collapse? i.e. use of sloping/benching/stepping
Is there any visible damage, cracking, collapse or other signs of
9.
weakening?
Are there access/egress points for excavation?
10.
Are spoil materials situated at least 1.5m away from the edge of
11.
the excavation?
Is spoil removed from the excavation kept at a suitable distance
12. away from the edge of the excavation? i.e. at least same width
away as depth of excavation
Have suitable barricades been installed around the excavation?
13.
i.e. physical barriers for vehicles; soft barriers for pedestrians
Traffic Management: -Are sufficient controls in place for
14.
pedestrian and/or vehicle crossing points?
Have toolbox talks been conducted and recorded to explain the
15.
hazards to workers?
Are there enough controls to prevent vibration from vehicles
16.
passing nearby?
17. Overhead power line protection measures?
Has the excavation been clearly signed to warn those working
18.
around the area? i.e. "Warning- Deep Excavation"
19. Is the PPE, required for the job being used by all correctly?
Is there sufficient lighting if the excavation works are carried out at
20.
night?
21. Is there protection for the public (suitable walkways, Signage etc?)
If adequate sloping /benching/stepping is not possible, have the
22.
use of trench boxes used to protect workers from collapse?
23. Weather conditions are favourable to the task being carried
24. Signals between plant operators & banks man are agreed
Has the operator been briefed on the PTW and the services (if
25.
any) in the area?
Comments:
Note: - If more space is required please attached additional sheets and/or pictures.
Site Engineer / Supervisor Name: Signature:

Randomly Verified by Site HSSE Officer Name: Signature:

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