Title Page
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Conducted on
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Site name
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Prepared by
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Location on site
Untitled Page
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SECTION A
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Name of company breaking ground, OCU Northavon or Sub Contractor
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Project Title
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Project details
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Date & time issued
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Site Manager in charge of works (Print name)
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Operatives
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(print name)
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(print name)
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This permit is valid from (Date)
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To (date)
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NB: IF THE EXCAVATION IS OVER 1.5M DEEP, THEN ADDITION CONTROL MEASURE WILL BE PUT IN PLACE. THESE COULD INCLUDE. The Health & Safety Manager will be informed who will oversee the task. Sub-Contractors RAMS will be reviewed by the site manager & the H&S Manager to ensure all identified hazards are covered and that risk is reduced as far as reasonably practicable. A tool box talk will take place before the task is started – this must include the SM, and/or the H&S Manager and the operatives doing the task
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SECTION B
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Precautions to be taken before work is carried out (To be completed by the site manager in charge of works’)
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Hazard identification (including residual and hazards introduced by the work)
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Potential contact with hidden services; gas, water, electrical, data has been identified?
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Contract drawings and details have been issued by the client?
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Live services made dead as far as possible or if necessary to do so
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Collapse of excavations have been identified?
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Falls into open excavations have been identified?
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Dust, from cutting/grinding have been identified?
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Noise issues have been identified?
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The following health & safety precautions will be taken:
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All available drawings have been checked, statutory undertakers contacted and all services marked out to the best of information available?
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CAT 4+ (Cable Avoidance Tool) scan undertaken by trained and competent person in the use of the scanner being used
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Operative training records have been checked and are in date?
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The operatives are clean shaven, have a suitable dust mask and records of face fit testing are available and checked?
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Location of services have been marked on the ground?
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Confirmed CAT equipment calibrated and checked?
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Temporary propping system employed?
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Dust suppression measures are in place and used?
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Acoustic screens erected where and if applicable?
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Suitable & sufficient RAMS are in place and have been explained to the operatives carrying out the task?
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The site Manager in charge of the excavation is fully conversant with the principles of safe digging and/or avoidance of underground services?
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If plant is being used, operator is competent and familiar with safe digging practices?
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Excavations will be covered at end of shift or wherever fall is possible?
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Chapter 8 barriers and/or other means of ensuring nobody can fall into the excavation will be used? please add detail of what methods are used.
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Service Location Drawings are available and have been checked as listed below?
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Water
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Gas
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Electric, <415V
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Electric, 412-11KV
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Electric, >11KV
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SECTION C
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Acceptance by the person breaking ground
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I have checked the intent of this permit and I am of the opinion that all known information has been checked / consulted and that the area is now marked ready for excavation/break out
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I agree that I/We will abide by the above precautions and will adhere to all OCU Northavon policies, procedures and rules whilst on site
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Signed by the person breaking ground
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Add signature
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Date:
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Authorised by the OCU Northavon SM and/or H&S Manager?
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Signed on behalf of OCU Northavon
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Position:
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Completion of work declaration (OCU Northavon or Sub-Contractor) person carrying out the excavation
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I hereby declare that the above-mentioned work has been completed and I/We have withdrawn from site, leaving all work areas tidy and safe
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Signed:
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Date:
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Suspension of work declaration (OCU Northavon or Sub-Contractor)
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I hereby declare that the above mentioned work has been suspended and I/We have withdrawn from site as of
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(date)
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I/We will resume work on the date and time as set out below
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(NB A new Permit To Work will be required on resumption of work)
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Signed:
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Date:
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Cancellation of Permit to Work
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(certifying work examined and left in safe condition)
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This Permit to Work is hereby cancelled from
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Date & time
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(On behalf of OCU Northavon)
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Only persons named on this permit will be allowed to carry out the above-named work and these persons will, at all times, be subject to all rules, policies and procedures in force at the location
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OCU Northavon will, so far is as is reasonably practicable, ensure that its legal and moral duties with regard to the health and safety of all persons working on its premises are met
