Permit to Work

Permit Number 1

Company Gibson Quarries Ltd Project IAS4 – Pines Park Lurgan

Works Location Boths sides of carriageway Contract No. GV.23.028

Single Activity Permit  Comments Drainage installation and gully installation
Multi Activity Permit

Section A. Project Details (To be completed by the Project / Contracts Manager)

Contractor Gibson Banbridge Ltd

Date/Time Issued 14/8/2023 Completion Date/Time 22/8/2023 17:00

(Max. 1 Week Duration)
Supervisor Jeff Hetrick Operatives

Works Description
Installing of 150mm dia carrier pipe along edge of carriageway. Depth of cover to be min 300mm . Bed and surround
with ST2 concrete. Level of dig to be determined on site.

Section B. Precautions (Pre Works) – to be completed by the Supervisor

Essential Procedures Yes No Comments

1. Are Service Drawings available; have these been reviewed? 

2. Do Service Drawings detail type and location of underground services? 

3. Services isolated ‘made safe’ if required? 

4. Works area surveyed (CAT Scanned) by a Competent Person?  By J.H and marked in RED.

5. Service locations conspicuously ‘Marked-up’?  By J.H and marked in RED

6. RAMS in place & communicated to ‘Dig Team’? 

7. Excavation Team competent/conversant in ‘Safe Dig’? 

8. Is ‘hand-digging’ required? 

9. Safe Access / Egress maintained throughout excavation? 

10. Collapse risk effectively controlled’? 

11. Will accumulated water need to be removed from the excavation’? 

12. Services known to be present

 Electricity   Gas Comments

 Telecommunications   Mains Water 

 Drainage   Other

1) Excavations completed in accordance with HSG 47 Avoiding danger from underground services.
2) Excavation WILL NOT take place unless the Permit to Work is completed, service drawings reviewed, a CAT scanned completed and identified
services conspicuously marked-up.
3) If additional/unidentified services are discovered, stop work and contact the Site Engineer / Manager.
4) Mechanical excavation shall not be used with 0.5m of identified services.
5) Personnel will have received information in relation to the associated RAMS (Risk Assessment / Method Statement) prior to the works
commencing.

Permit to Work FM01-002B – Issue 02

 Permit to Work
Section C. Permit Confirmation – to be completed by the Supervisor & Operators

Supervisor Name Jeff Hetrick Signature

Position Foreman Date

Operator Names Signatures

Note – Continue
on a separate
sheet if required.

Section D. Works Completion– to be completed by the Supervisor

I am satisfied that:
1) No damaged of any exposed utilities has taken place. Note – If damaged has occurred, please provide details, including photographs in the
section below.
2) The excavation has been suitably backfilled / covered / protected.
3) The utility company(s) have been informed that any services that have been ‘made-dead’ can now be reactivated.
4) The works have been completed in accordance with specification.
5) Information is relation to any diverted services has been passed onto the Site Engineer so the ‘As-built’ drawings can be appropriately
amended.
6) Information in relation to any unidentified services has been passed onto the Site Engineer so the ‘As-built’, drawings can be appropriately
amended.

Name Jeff Hetrick Signature

Position Foreman Date

Details of any additional works or damage

Additional Works

Damage Details

Section E Cancellation of the Permit to Dig (To be completed by the Site Engineer / Contracts Manager)

I am satisfied that:
1) That the works has been completed in accordance with specification.
2) The excavation has been suitably reinstated or protected and does not pose a H&S risk.
3) The Service Drawings have been appropriately updated (marked-up); including the location of any services previously not detailed in the
Service Drawings.
4) The works have been completed in accordance with specification.

Name Brendan McAteer Signature

Position Site Engineer Date

Comments

Permit to Work FM01-002B – Issue 02

 Permit to Work

Permit to Work FM01-002B – Issue 02