excavation permit form pdf

Excavation Permit

Section 1: Permit & Job Information

Project / Job Title

Permit No.

Work Area / Facility

Specific Location / Street Address

Valid From Date

Valid From Time

Valid To Date

Valid To Time

Section 2: Scope of Work & Dimensions

Detailed Description of Work to be Performed

Maximum Depth (in feet/meters)

Approximate Dimensions (LxW in feet/meters)

Section 3: Excavation Safety Checklist

Utility locates completed & marked Excavation site clearly marked Shoring/sloping plans in place Barricades & signage erected Egress/access for depths > 4ft Spoil piles 2ft from trench edge Emergency rescue plan reviewed Required PPE available & inspected Atmospheric testing performed

Specific Safety Notes or Precautions

Section 4: Authorization & Acceptance

Permit Issuer

Name

Signature

Date & Time

Work Supervisor / Applicant

Name

Signature

Date & Time

Section 5: Permit Closure & Backfill

I hereby confirm that all work is completed and the site has been backfilled and left in a safe condition.

Permit Closed By (Work Supervisor)

Name

Signature

Date & Time

Handover Accepted By (Area Supervisor)

Name

Signature

Date & Time

Our Company:

Solutions:

Contact Us: