ROAD WORKS PERMIT PERMIT NO:

Project: Bangladesh Greater Dhaka Sustainable Urban Transport Project (BRT, GAZIPUR- Airport)

SECTION A
Road Works Details : Excavation/ road breaking Sub-Base Preparation Sub base Works Tack Coat/prime Coat Works

Asphalt Work PQC works U –Drain Works Foot path works Catch pit Works others:

Chainage/ Location:

Permit valid: Permit valid from Date: Permit Valid till Date:

Section B: Hazard Identified: To be completed by Job Performer, Permit Issuer & Permit Approval.

Identify Potential Hazards

Traffic Hazard Construction Equipment movement Drowning hazard
Slip /Trips Hazard Reversing equipment Overhead Electrical line
Improper Access//Egress Poor Visibility / Illumination Lifting activity Hazard
public movement Manual Handling Hazard Dust Hazard
high speed traffic flow adverse weather conditions, Noise Hazard
Improper/No Barricading Public Unauthorized Entry

Section C: Identified HSE Control Measures: To be identified by Job Receiver, Permit Issuer & Permit Approval
Documents/Permits/Control Driving License Personal Protective Equipment PPE
Method Statement (MS) Equipment third party certificate Safety Helmet
Risk Assessment(RA) Flagman for reversing vehicle Safety shoes
Tool Box Talk Traffic Controllers Visibility vest
Safety Induction Entry/exit Point for construction vehicle Safety Glasses
Proper Road Closure traffic Controller Hand Gloves
Plastic barricade/Green Net Speed Limit Posted Supervisor Presence
traffic signage’s- No Entry/Slow Flash Light during night works
Down/Men At Work

Section D: Acceptance, Validity, Approval, Extension : Completed by Job Performer, Permit Issuer& Permit
Approval
Work site inspected, identified controls measures are in place, hazards and control measures communicated to workers and permit
conditions are satisfactory.

Date Date Date Date Date Date Date

Permit Concern Party

Job Receiver
Supervisor/ FM/( Sign
)
Permit Issuer
Engineer ( Sign )

Permit
Approval(HSE) Safety
Officer (Sign )
Section E: Permit Close Out (To be completed by Job Performer & Permit Issuer and Permit Approval )
Work is incomplete, Close and Issue new permit Work is completed, area is safe /secured. Close this Permit.
Name Signature Mobile No

Permit Receiver

Permit Issuer

Area Safety Officer