Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
SMS Form - Permit to dig (Draft)
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Breaking ground
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Permit To Dig / Break Ground (Page 1) Work must not start until section a,b and c have been completed and signed by authorised person
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Company Name
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Project Title
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Locations
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Contract No
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SECTION A - Project Details to be completed by project or package manager
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Contractor
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Date & Time Issued
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Completion Date
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Supervisor in Charge of Works Print Name
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Operatives Print Names
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Brief Description of Works
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SECTION B – Precautions to be taken before work is carried out (to be completed by Supervisor in charge)
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Essential procedures
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Contract drawings and details issued by client or otherwise obtained
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Drawing show location, type and status of underground services
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Live services made dead as far as possible for necessary to do so
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Work area surveyed by competent person using appropriate detection equipment to confirm the exact location of underground services
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Location of services marked on ground
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Valid risk assessment and method statement in place
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Method statement and risk assessment explained to operatives carrying out the work
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Person in charge of excavation is fully conversant with the principles of safe digging and /or avoidance of underground services
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All operatives familiar with safe excavation practices
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If plant is use, operator to be competent and familiar with safe digging practices
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State type, serial number and calibration test date of cable avoidance equipment
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Confirmation by Contractors 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
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Name
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Position
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Signature
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Date
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PERMIT TO DIG / BREAK GROUND (page 2)
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Confirmation by Operators(s): I understand the precaution to be taken in carrying out the works
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Name
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Position
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Signature
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Date
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SECTION C - COMPLETION OF WORK
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(To be completed by the supervisor in charge of the works)
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I am satisfied that:
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The excavation has been backfilled and the surface re-instated*
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The works has been completed and the area has been left in a safe condition*
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The work area is clear of operatives and all equipment*
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Utility company(ies) have been informed that services made dead may be re-activated*
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I am NOT satisfied that the work has been completed satisfactorily and that the additional work decribed below must be completed before this permit can be cancelled*
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*delete as appropriate
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Name
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Position
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Signature
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Date
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Additional work that is necessary to enable this permit to be cancelled
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SECTION D. CANCELLATION OF PERMIT. (To be completed by the supervisor in charge of the work)
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I am satisfied that all work has been completed and this permit is now cancelled
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Name
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Position
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Signature
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Date
