Title Page
-
Exact location where ground will be broken
-
Conducted on
-
Permit prepared by
-
Location
-
Street works permit number
Permit details
-
Complete by - Site Supervisor/ Crew leader
-
Contractor name
-
Date & Time of issue
-
Completion Date:
-
Supervisor
-
Operatives Name(s)
-
Brief description of works:
Complete by Site Supervisor
-
Are contract drawings and details issued and available on site for inspection
-
Do the drawings on site show the location, type and status of underground services
-
Is there a CAT4 and Genny on site within calibration – provide details of the type, serial number and calibration date in comments box
-
Is there is a competent person available to undertake a survey of buried utilities
-
Is there a detailed and thorough utility service survey been undertaken and all services marked and identified
-
Has a safe place to break ground been identified- provide details and comment
-
Is the person in charge of the excavation fully conversant with the principles of safe digging (HSG47) and service avoidance
-
Do all personnel involved in excavation have suitable flame-retardant PPE (Class 3)
-
Are all personnel involved in digging operation competent and understand the principles or safe digging/avoidance of services
-
Is a valid risk assessment and method statement available for inspection
-
Has a safe approach and method of work been agreed and explained to the operatives carrying out or who are involved in the work
-
Has the method of work considered the environmental impact and does it pose any significant concerns or if concerns have been identified have they been discussed and suitable controls put in place and understood by site personnel
-
Are all hand tools to be used insulated and in good order
-
If mechanical plant is used, is the operator is trained, competent and familiar with safe excavation practices
-
The excavation is not expected to exceed 1.2 metres deep and grounds conditions have been considered and no temporary works or battering is anticipated
-
The excavation is planned to be over 1.2 and suitable temporary works support is available with competent personnel on site to install – provide details on comments section or over leaf if more space is required
-
Confirmation by contractor’s supervisor: I confirm that the precautions specified above will be complied with and I will ensure that the persons carrying out the work, described above, are fully briefed on the safe method of work
-
Name
-
Position
-
Signature
-
Date
-
Confirmation by Operators: I confirm I understand the precautions and agreed approach of safe digging
-
Name
-
Position
-
Signature
-
Date
-
Name
-
Position
-
Signature
-
Date
-
Name
-
Position
-
Signature
-
Date
Review & Completion of Work – to be completed by the supervisor in charge of the work
-
I am satisfied that
-
I inspected the excavation prior to reinstatement and confirm there were no utility services damaged
-
The excavation has been backfilled and surfaced reinstated
-
The works has been completed and the area has been left in a safe condition
-
The work area is clear of operatives and equipment
-
Complete when works inspected but indicate if additional works are required
-
Name
-
Position
-
Signature
-
Date
-
Indicate Number of areas not completed whilst on site
-
This should only be fully signed off when all listed works have been completed
-
Name
-
Position
-
Signature
-
Date
-
Wildanet Supervisor counter sign to demonstrate they have received permit and they have checked the site and works are completed
-
Position
-
Signature
-
Date
