Title Page
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Conducted on
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Prepared by
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Location
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Job/ Contract Number
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Site team members
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Start time
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Anticipated completion time - NOTE :- If not completed on the same day a new Permit should be completed each day.
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Brief Description of Work
A - Safety Elements and Checks Completed Before Work Starts
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Drawings on site which show the location, type and status of underground services
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There is a CAT4 and Genny on site and within calibration – provide details of the type, serial number and calibration date in comments box
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There is a competent person available to undertake a survey of buried utilities
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A detailed and thorough utility service survey has been undertaken and all services marked and identified
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Safe place to break ground has been identified
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Method of breaking ground
- Road saw
- Cut-off saw
- Mechanical breaker
- Pecker
- Hand tools
- Other
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State method used
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All personnel involved in excavation have suitable flame-retardant PPE (full shelves and legs)
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All personnel involved in digging operation are competent and understand principles or safe digging and /avoidance of services
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Valid risk assessment and method statement are in place
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A safe approach and method of work has been agreed and explained to the operatives carrying out or involved in the work
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The method of work has considered environmental impact and doesn’t pose any significant concerns or if concerns have been identified these have been discussed and suitable controls put in place and understood by site personnel
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All hand tools to be used are insulated and in good order
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If mechanical plant is used the operator is trained, competent and familiar with safe excavation practices
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Type of Mechanical plant to be used
- Mechanical Excavation
- Mole Plough
- Chain Trencher
- Air Pick
- Vacuum Excavation
- Other
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State type of plant used for digging
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The excavation is expected to less than 1.2 metres deep and grounds conditions have been considered and no temporary works or battering is anticipated
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The excavation is planned to be over 1.2 metres (or less than 1.2 metres with lose or unstable ground conditions)
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The excavation is planned to be over 1.2 metres (or less than 1.2 metres with lose or unstable ground conditions) and suitable temporary works support is available with competent personnel on site to install – provide details on comments section and photos must be taken when installed.
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provide details of temporary works plan and photos to demonstrate what is in place
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Trial holes required
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State number of logic for location etc - pictures to be provided when completed
Photos to demonstrate it is Safe to Dig
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Include photos of the following and anything else which shows its safe to dig - must include CAT and Genny (include service information), utility mark up (different colours), Safe place to dig (Marked as SP), Tools to be used (Insulated hand tools / mechanical) Suitable flame retardant PPE and any other relevant physical thing relating to the site.
B - Sign Off and Briefing
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All personnel listed on the Permit understand how to undertake the excavation - If not you cannot commence digging
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I confirm that the precautions specified above will be complied with and will ensure that the persons carrying out the work follow the agreed safe method of work agreed
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Having considered all the factors detailed above I consider it safe to proceed - but will STOP work if circumstances change significantly and may affect safety.
JFL Supervisors Section
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Name
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Date
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Details of current progress
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Additional controls or concerns you have raised with site team
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Was it necessary to STOP work due to SHE Concerns
- Yes
- Some issues rectified but work continued
- No work safe to continue
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Are there any lessons learnt for next time or suggested improvements
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Signature
