Declaration

This section must be completed following the completion of all works which require breaking the ground.

Did any incidents/accidents involving contact with underground services occur?

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:

I am satisfied that the excavations have been backfilled and the surface reinstated suitably.

I am satisfied the work is completed and the area has been left in a safe condition.

I am satisfied that the work area is clear of operatives and all equipment.

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.

Photograph of site after works complete:
Permit closed:
Completed By:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.