Title Page
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Prepared by
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Location of site:
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Date/Time
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Job reference number:
Declaration
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This section must be completed following the completion of all works which require breaking the ground.
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Did any incidents/accidents involving contact with underground services occur?
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If yes to the above then please provide brief details of the incident and immediately inform your line manager if you have not already done so:
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I am satisfied that the excavations have been backfilled and the surface reinstated suitably.
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I am satisfied the work is completed and the area has been left in a safe condition.
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I am satisfied that the work area is clear of operatives and all equipment.
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Please provide details if any additional work that is necessary to enable this permit to be closed. If any additional work is described below, it must be completed before this permit is closed.
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Photograph of site after works complete:
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Permit closed:
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Completed By:
