Permit Number:………………

EXCAVATION WORK PERMIT

(TCPL Green Energy Solutions Private Limited)

Work by: □ Employee □ Supplier (Write name):

Date: Start time: Completion time:
Extension required up to time:
Area of Work & Exact work location:
Permit Owner __________ BUL____________
Permit Owner:
Description of work:

Permit Owner Name: Signature:

* I explained all the safety requirements w.r.t. Excavation work permit and work-related hazards to Permit Acceptor.

Electrical/Civil/ IT In-charge:
I have Inspected area w.r.t Utilities lines, IT & Communication lines, Structural Analysis requirements , the area is safe,
and work can be permitted for above task.

Electrical In-charge: Civil in charge: IT in charge:

BUL:
I reviewed, the area is safe and work can be permitted for above task. I ensure that the all affected employee shall be
communicated of the hazard.

BUL Name: Signature:

Permit Acceptor:
I ensure that the area shall be continuously under supervision from start to completion of the job and all required
displays/ warnings/ indications shall be maintained throughout the job execution period. I understand the Excavation
work to be performed and the necessary safety precautions to complete the work safely as outlined in this permit,
method statement and/or risk assessments. If conditions change to the extent that this permit, the method statement
and risk assessments become invalid, it is my responsibility to stop work immediately and notify the Initiator.

Permit Acceptor Name: Signature:

Permit Approver:
I inspected the area is safe w.r.t Excavation work permit requirement and work can be permitted for above task.
Additional Comments: -

Permit Approver Name: Signature:

Sl. No. Name of the Person Carrying out the Work Safety Harness Sl. No. Signature

Closing of Permit / Final check

Permit Acceptor:
I declare that the work described above is complete all work equipment, persons and materials under my control have
been withdrawn. All safeguards have been reinstated, Housekeeping is adequately done and the work area returned to
a safe status and service. I also declare that the permit is ready to close.

Permit Acceptor Name: Signature:

Permit Owner:
I formally close the Permit hence all the work done and now area is fully safe from above completed task

Permit Owner Name: Signature:

Check the box when an item has been completed. Permit Shall not be issued until following precautions have been checked.

Format No: HSEMS-OCP-01-F-05 Revision No: 01 Revision Date: 25/07/2020

Yes N/ARequirement
Which of the following hazards are associated with this work?
Vehicle Movement [ ] Utilities/ Overhead Electric Cables [ ] Unguarded Edges [ ]
Falling Objects / Debris [ ] Uneven Floor Surfaces [ ] Lack of Space [ ]
Manual Handling of Loads [ ] Unsecured Ladders [ ]
General Inspection of Job Site
[ ] [ ] Excavations, adjacent areas and protective systems inspected daily by a competent person before the start of work.
[ ] [ ] Personnel protected from loose rock or soil that could pose a hazard by falling or rolling into excavation.
[ ] [ ] Hard hats worn by all personnel.
[ ] [ ] Spoils, materials, and equipment set back at least 1mtr/ 3 ft from the edge. Competent person has the authority to
remove personnel from the excavation immediately.
[ ] [ ] Barriers provided at all remotely located excavations, wells, pits, shafts…
[ ] [ ] Walkways and bridges over excavations 1 mtr/ 3 ft or more in depth are equipped with standard guardrails and toe
boards.
[ ] [ ] Warning vests or other highly visible clothing are provided and worn by all persons.
[ ] [ ] Personnel prohibited from going under suspended loads
[ ] [ ] Personnel prohibited from working on the faces of slopes or benched excavations.
Utilities:
[ ] [ ] Utility department contacted and/or utilities located. Exact location of utilities marked.
[ ] [ ] Underground installations protected, supported, or removed when excavation is open.
[ ] [ ] Energized electrical systems and/ or equipment (including electrical cables, underground and overhead) are de-
energized (locked out) and/ or safely routed.
Means of Access and Egress:
[ ] [ ] Lateral travel to means of egress no greater than 8mts/ 24 ft in excavations 1.5mts/ 4 ft or more in depth.
[ ] [ ] Ladders used in excavations secured and extended 1m/ 3 ft above the edge.
[ ] [ ] Structural ramps used by personnel designed by a competent person.
[ ] [ ] Ramps constructed of materials of uniform thickness, cleated together on the bottom, equipped with a non-slip surface
[ ] [ ] Personnel protected from cave-ins when entering or exiting the excavation.
Wet Conditions:
[ ] [ ] Precautions taken to protect personnel from the accumulation of water.
[ ] [ ] Surface water or runoff diverted or controlled to prevent accumulation in the excavation
[ ] [ ] Inspections are made after every rainstorm or other hazard increasing occurrence
Hazardous Atmosphere:
[ ] [ ] Atmosphere within the excavation tested where there is a reasonable possibility of an oxygen deficiency, combustible or
other harmful contaminant exposure.
[ ] [ ] Adequate precautions taken to protect personnel from exposure to an atmosphere containing less than 19.5% of oxygen
and/or to other hazardous atmospheres.
[ ] [ ] Ventilation provided to prevent personnel exposure to an atmosphere containing flammable gas in excess of 10% of the
lower explosive limit of the gas.
[ ] [ ] Testing conducted often to ensure that the atmosphere remains safe.
[ ] [ ] Emergency equipment, such as breathing apparatus, safety harness and lifeline, and/or basket stretcher readily
available where hazardous atmospheres could or do exist.
[ ] [ ] Personnel trained to use personal protective and other rescue equipment. Safety harness and lifeline used and
individually attended when entering confined spaces.
Support Systems:
[ ] [ ] Materials and / or equipment of support systems selected based on soil analysis, trench depth and expected loads.
[ ] [ ] Materials and equipment used for protective systems inspected and in good condition.
[ ] [ ] Materials and equipment not in good condition have been removed from service.
[ ] [ ] Protective systems installed without exposing personnel to the hazards of cave-ins, collapses, or threat of being struck
by materials or equipment.
[ ] [ ] Backfilling progresses with removal of support system
[ ] [ ] Excavation of material to a level no greater than 0.5mts/ 2 ft below the bottom of the support system and only if the
system is designed to support the loads calculated for the full depth

[ ] [ ] Is there a specific method statement required? (if yes, attach it to this permit)
[ ] [ ] Does the work involve any of the following? (Use appropriate permits in addition)
Hot Work [ ] Work at height [ ] Isolation (LOTO) [ ] Others [ ] (Specify): __________
In the event an emergency, call (Phone): 0657–6131–204/207
and use the alarm box located at ________________________________

Format No: HSEMS-OCP-01-F-05 Revision No: 01 Revision Date: 25/07/2020