1. Project Information: (To be filled by initiator/originator) Project Name: Permit No.: Project Location: Requesting Contractor/Company 2. Permit Issuance Details: (To be filled by initiator/originator) THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE Description of Task: Detail of Surroundings: Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date: 3. Excavation Details: (To be filled by initiator/originator) Location of Excavation: Click here to enter text. Excavation Dimensions: ☐ Depth: Enter Depth ☐ Width: Enter Width ☐ Length: Enter Length ☐ Other(s): Enter Others Type of Excavation: ☐ Ditches ☐ Trenches ☐ Shafts ☐ Tunneling (drilling /Boring) ☐ Well ☐ Post Driving ☐ Other(s): Enter Others Excavation Tools/ Equipment ☐ Hand Shovel ☐ Pickaxe ☐ Excavator ☐ Shovel ☐ Skid steer Loader ☐ Backhoe Loader ☐ Other(s): Enter Others Identified Underground Service(s): ☐ Electrical ☐ Sewer/ Water ☐ Drainage ☐ Communication/Data ☐ Gas ☐ Other(s): Enter Others Underground Condition(s): ☐ Water Table, Depth: Enter Depth ☐ Tanks ☐ Vaults ☐ Wells ☐ Void & structure ☐ Chemicals ☐ Volatile Fuels ☐ Toxic Gases ☐ Other(s): Enter Others Excavation Protection(s) By: ☐ Slope, (in degrees from horizontal) Enter Angle as per soil condition ☐ Benching ☐ Sheet, Waling, Strutting ☐ Soldier piling ☐ Void & structure ☐ Proprietary support system ☐ Other(s): Enter Others Notification(s) given to( If Required): ☐ Relevant Authorities: Click here to enter text. ☐ Utility Service Provider(s): Click here to enter text. ☐ Owner Of Adjoining Properties : ☐ Other(s): Click here to enter text. 4. Control Measures: (To be filled by initiator/originator and verified by Evaluator) Checks Yes-No-NA Checks Yes-No-NA Applicable NOCs available ☐ ☐ ☐ Safe means of access/egress provided ☐ ☐ ☐ Method statement & Risk assessment developed, approved & communicated? ☐ ☐ ☐ Ladder are secured, fixed & maintained ☐ ☐ ☐ Operatives are trained and competent? ☐ ☐ ☐ Workplace appropriately illuminated ☐ ☐ ☐ Site is surveyed correctly, marked and identified ☐ ☐ ☐ Ventilation means are available ☐ ☐ ☐ All underground services checked & validated ☐ ☐ ☐ Proper signage are posted ☐ ☐ ☐ Certified cable detector used to verify above ☐ ☐ ☐ Adequate barricade to prevent fall of person/vehicle ☐ ☐ ☐ Ground conditions are examined with bore/trial pit ☐ ☐ ☐ Flash light are fixed on the barricades ☐ ☐ ☐ Water table is located ☐ ☐ ☐ Trained flagman deputed to caution traffic ☐ ☐ ☐ Adjacent properties/services exist? Inspected? ☐ ☐ ☐ Adequate traffic diversion is provided ☐ ☐ ☐ Stability of adjacent property structure ensured/secured ☐ ☐ ☐ Trained banksman available for plants ☐ ☐ ☐ Adequate arrangement to prevent Cave-in ☐ ☐ ☐ Mandatory/specific good condition PPEs are available ☐ ☐ ☐ Dewatering arrangem

1. EXCAVATIONPERMIT
Page 1 of 3 Form # HSEQ – EP (Rev 3 - Mar 23)
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:
Detail of Surroundings:
Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:
3. Excavation Details: (To be filled by initiator/originator)
Location of Excavation: Click here to enter text.
Excavation Dimensions: ☐ Depth: Enter Depth
☐ Width: Enter Width
☐ Length: Enter Length
☐ Other(s): Enter Others
Type of Excavation: ☐ Ditches
☐ Trenches
☐ Shafts
☐ Tunneling (drilling /Boring)
☐ Well
☐ Post Driving
☐ Other(s): Enter Others
Excavation Tools/ Equipment ☐ Hand Shovel
☐ Pickaxe
☐ Excavator
☐ Shovel
☐ Skid steer Loader
☐ Backhoe Loader
☐ Other(s): Enter Others
Identified Underground
Service(s):
☐ Electrical
☐ Sewer/ Water
☐ Drainage
☐ Communication/Data
☐ Gas
☐ Other(s): Enter Others
Underground Condition(s): ☐ Water Table, Depth: Enter Depth
☐ Tanks
☐ Vaults
☐ Wells
☐ Void & structure
☐ Chemicals
☐ Volatile Fuels
☐ Toxic Gases
☐ Other(s): Enter Others
Excavation Protection(s) By: ☐ Slope, (in degrees from horizontal)
Enter Angle as per soil condition
☐ Benching
☐ Sheet, Waling, Strutting
☐ Soldier piling
☐ Void & structure
☐ Proprietary support system
☐ Other(s): Enter Others
Notification(s) given to( If
Required):
☐ Relevant Authorities: Click here to enter text.
☐ Utility Service Provider(s): Click here to enter text.

2. EXCAVATIONPERMIT
Page 2 of 3 Form # HSEQ – EP (Rev 3 - Mar 23)
☐ Owner Of Adjoining Properties :
☐ Other(s): Click here to enter text.
4. Control Measures: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Applicable NOCs available ☐ ☐ ☐ Safe means of access/egress provided ☐ ☐ ☐
Method statement & Risk assessment developed,
approved & communicated?
☐ ☐ ☐ Ladder are secured, fixed & maintained ☐ ☐ ☐
Operatives are trained and competent? ☐ ☐ ☐ Workplace appropriately illuminated ☐ ☐ ☐
Site is surveyed correctly, marked and identified ☐ ☐ ☐ Ventilation means are available ☐ ☐ ☐
All underground services checked & validated ☐ ☐ ☐ Proper signage are posted ☐ ☐ ☐
Certified cable detector used to verify above ☐ ☐ ☐
Adequate barricade to prevent fall of
person/vehicle
☐ ☐ ☐
Ground conditions are examined with bore/trial pit ☐ ☐ ☐ Flash light are fixed on the barricades ☐ ☐ ☐
Water table is located ☐ ☐ ☐
Trained flagman deputed to caution
traffic
☐ ☐ ☐
Adjacent properties/services exist? Inspected? ☐ ☐ ☐ Adequate traffic diversion is provided ☐ ☐ ☐
Stability of adjacent property structure
ensured/secured
☐ ☐ ☐ Trained banksman available for plants ☐ ☐ ☐
Adequate arrangement to prevent Cave-in ☐ ☐ ☐
Mandatory/specific good condition PPEs
are available
☐ ☐ ☐
Dewatering arrangement are in place ☐ ☐ ☐
Emergency procedures are developed
and communicated
☐ ☐ ☐
Standby dewatering pump available, maintained ☐ ☐ ☐
Precaution Taken for waste
Management
☐ ☐ ☐
Dewatering water drained out at appropriate &
approved place
☐ ☐ ☐ Other(s): ☐ ☐ ☐
Site Security deputed to avoid unauthorized entry ☐ ☐ ☐
5. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives,
and I consider them competent to do it safely.
Initiator/Originator
Name:
Designation:
Signature: Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Time
Comments (if any):
6. Authorization (PM/CM):
Name: Designation:
Signature: Time:
7. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.

3. EXCAVATIONPERMIT
Page 3 of 3 Form # HSEQ – EP (Rev 3 - Mar 23)
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time: