Title Page

  • Work Site

  • Site Location Plots/Area

  • Prepared by

Permit Request

  • Work Activity Title (Description)

  • Specified high-risk work tasks covered to work by this permit

  • Start of Work

  • Duration of Permit

Service Drawings

  • Have Site inductions and RAMS been briefed and signed

  • Are on-site service drawings available and have operatives carrying out the works been briefed on existing services.

CAT & Gennie

  • Does at least one of the team hold a valid in date (3 years) CAT & Genny qualification?

  • CAT & Genny Serial Number

  • CAT & Genny Calibration Date

Trial Holes

  • For identified services, have trial holes been dug by hand to ascertain service depths?

  • Will hand digging with insulated tools be used when digging trial holes?

  • What services were found?

  • What depths where services located?

  • Have service routes been marked with paint/pins?

  • Are works deemed safe to proceed?

  • Full Name and Signature of Supervisor

Safe Trench/Excavation Practices

  • Are Trench boxes being used for these works exceeding 1.2m?

  • Will shallow excavations be stepped or battered back?

  • When digging around services, will insulated tools be used?

Plant & Equipment

  • Has all plant undergone a weekly inspection?

  • Are all operatives trained to operate plant?

Works briefed and Explained

  • Full Name and Signature of Supervisor

  • Full Name and Signature of Excavator Operator

  • Full Name and Signature of Other Operatives

  • Full Name and Signature of Other Operatives

  • Full Name and Signature of Other Operatives

Completion of Works Sign-off

  • Full Name and Signature of Supervisor

  • General Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.