Permit to Break Ground rev 1

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

• Project:

• Project No.:

• Issue Date:

  Date

• Time:

  Date

• Location:

• Permit No.:

• Expiry Date:

  Date

• Time:

  Date

SECTION 1: PLANNING AND PREPARATION

• To be completed by Supervisor directly responsible for the works

• Detailed description of the works and Limitations: i.e excavator, hand dig, known services

Method Statement & Risk Assessment Ref No.:

• Method Statement and Risk Assessment Number

• Review Date:

  Date

• Attached Drawing / Sketch Reference:

• Are temporary works required:

  Yes

  No

  N/A

• If yes, state temporary works design check certificate reference number:

• Depth of excavation:

• Width of excavation:

• Width of excavation with batter / stepping:

• Any Temporary support for services:

• Are current issue drawings showing location, type and status (i.e. live or dead) of all known services in the area of dig available?

  Yes

  No

  N/A

• Are existing service drawings available?

  Yes

  No

  N/A

• Have trial holes been carried out?

  Yes

  No

  N/A

• Has a visual survey of the location of the dig been carried out?

  Yes

  No

  N/A

• Has a calibrated cable locating device been used to survey the area to establish the location of any known and uncharted cables?

  Yes

  No

  N/A

• Are operatives conversant with safe digging practices HSG 47?

  Yes

  No

  N/A

• Will the operative have competent supervision? (SSSTS/SMSTS)

  Yes

  No

  N/A

• Are flame retardant clothing available? This must be worn by the persons hand excavating around live electrical services

  Yes

  No

  N/A

• Note: If any of the above items have been answered “NO” or there is any other Hazard identified then work can not start until a Specific Risk Assessment has been undertaken describing how the risks are to be controlled

• The following services have been identified on the site services drawing, as-builds and GPR survey

  Yes

  No

  N/A

• Electric Cable

  Yes

  No

  N/A

• Size and voltage

• Gas Main

  Yes

  No

  N/A

• Type, size, pressure

• Water Main

  Yes

  No

  N/A

• Type and size

• BT / Comms

  Yes

  No

  N/A

• Type

  Yes

  No

  N/A

• Surface Water

  Yes

  No

  N/A

• Foul Water

  Yes

  No

  N/A

• Other:

SECTION 2: CONFIRMATION OF PLANNING AND PREPARATION PROCESS HAS BEEN COMPLETED

• Applicant / Supervisor: I hereby declare that the above precautions will be put into effect prior to the works commencing and all relevant services drawings are attached to this permit

  Sign

• Name:

• Position:

SECTION 3 AUTHORISATION TO PROCEED

• I have witnessed the trial holes and confirm that the identified services have been exposed. I am satisfied that the precautions identified above are satisfactory for the works to be undertaken.

  Yes

  No

  N/A

• Name

• Position

• Date

• Time

• Signature

  Sign

SECTION 4:COMMUNICATION OF PERMIT

• I have had the requirements of this permit and the risk assessment and method statement for the activity explained to me. I understand the “safe digging” techniques to be used.

• Name

• Position

• Date

• Signature

  Sign

• Name

• Position

• Date

• Signature

  Sign

SECTION 5: CLEARANCE AND CANCELLATION

• I hereby confirm that the work to which this permit relates to is now complete. All operatives and materials are now cleared from the work area. The area of the excavation has been left in a safe condition, i.e. physical/visible edge protection, warning notices, securely fixed marked covers or back filled etc.

• Is the permit being cancelled

  Yes

  No

  N/A

• Name

  Yes

  No

  N/A

• Position

  Yes

  No

  N/A

• Date

  Yes

  No

  N/A

• Signature

  Yes

  No

  N/A