EXCAVATION PERMITS № ExP an attachment to GWP_____

I. Details
Task description:________________________________________
Location of work:________________________________________
Date:____________
Requested by:__________________________________________
(Contractor Performer)
DANGER!!!
 Collapse of excavation
 Fall of personnel and equipment
 Damage to electrical and water lines
 Electrocution due to contact with live electrical lines.
DO NOT DO ANY EXCAVATION WORKS UNTIL THE
FOLLOWING PRECAUTIONS HAVE BEEN TAKEN!

Type of excavation:
The performer has to check each item:
Yes No
□ Foundation □ Trench
□ Tunneling
1. The location
□ Embankment
where the work is to be done
□ Other have
type, specify
been personally examined by the Technical
Supervisor.
2. Plans and details have been provided to
1. Length___________
determine detailsWidth_________
and presence Depth____________
of embedded
2. item.
Is the risk Assessment attached to the permit Yes / No
3. The3.Excavation
The following safeguards
Clearance shall beattached
Certificate provided:to the
permit?
A. Yes / No
Identification of underground utilities has
been done thru a clearance certificate?
Reviewed by:
B. Isolation of electrical & water lines has
____________________________________
been done?
ACC Civil ( if required).
Supervisor (Name/Signature/Date)
CoordinatedC.by:Spotter is assigned to guide mobile
___________________________________
equipement?
ACC Safety Coordinator /Name/Signature//Date)
D. Provision of barricades and cordon to
prevent
Permitted to equipment
proceed by: and personnel from falling
has been done?
___________________________________
ACC Construction Manager (HOD)/Name/Signature//Date)
E. Has provision of warning signage been
done?
F. Is illumination provided for night works?
G. Will the excavation result into a confine
space? Refer to Confined Space Entry
procedures in the Safety Procedure is so.
III. Turn over
H. Is the excavation provided w/ adequate
access or ladders?
Work completion & turn over:

1. I. Is the
The work shoring
for which provided?
this Permit was issued has been
properly performed
2. J. have
All men Is the excavation
been sloping
withdrawn, that alland
toolsbenching
and equipment,
done?
plant and electrical apparatus affected by the work have
been left in a safe, clean condition.
K. Excavated materials and spoils are kept 2
3. Turnedmeters away from the edge?
over by;

___________________________________________
Contractor/ Performer
I commit to Implement and monitor the above safety controls and
4. conditions
Checked on siteby;
& verified until the job is completed. I understand that
failure to implement will be grounds for cancellation of this permit.
_______________________________________
by: ACC Technical Supervisor

_______________________________________
_____________________________________
ACC Safety Coordinator
Performer’s Name/ /Signature/ Date
5. Accepted
by:_________________________________________
ACC Line Manager ( HOD)