Permit to Break Ground Rev 2

Title Page

Untitled Page

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 and Risk Assessment Number
Review Date:
Attached Drawing / Sketch Reference:
Are temporary works required:
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?
Are existing service drawings available?
Have trial holes been carried out?
Has a visual survey of the location of the dig been carried out?
Has a calibrated cable locating device been used to survey the area to establish the location of any known and uncharted cables?
Are operatives conversant with safe digging practices HSG 47?
Will the operative have competent supervision? (SSSTS/SMSTS)
Are flame retardant clothing available? This must be worn by the persons hand excavating around live electrical services
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
Electric Cable
Size and voltage
Gas Main
Type, size, pressure
Water Main
Type and size
BT / Comms
Type
Surface Water
Foul Water
Other:

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
Name:
Position:

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.
Name
Position
Date
Time
Signature

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
Name
Position
Date
Signature

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
Name
Position
Date
Signature