Whsmp · OPW16/0021

                                                                                       Excavation & Penetration Permit
                                                                                       HB-HSEQ-F-078ERROR! UNKNOWN DOCUMENT PROPERTY NAME.
                                                                                                                                  Version: 7



                                                                                                             Permit No.
Section 1 – General Details
Subcontractor:
Project & Address:
Work Activity Description:
Location of work:
Special access restrictions
(due to the task involving specific plant)
Excavation type(s):                                           Bulk Cut                      Trenching                       Drilling / piling
Section 2 – Documentation for Underground Essential Services
               Yes NA Control
                                   Have investigations been undertaken to identify existing services effected by the excavation /
Identify                           penetration works
essential steps                    Is there a documented plan showing all existing services that may be effected by the excavation
in identifying                     activities
the status of                      Does the plan identify type of service, location, depth and live services in the area :
existing                                Water/Fire           Sewer                Electrical HV          Electrical LV        Electrical L
services
                                       Storm water       Fibre Optic        Fuel/Gas            Communications/phone
                                   Has there been a review undertaken to identify any building design requirements to offset damage
                                   to existing services
Section 3 – Specific Operational Controls
Requirement                                                                                                 If Yes, Include Additional Control
                                                                                            Yes     NA      Details to be Used:
Have the services that may be affected by the work been clearly mark out on the area
being excavated or drilled?
Has a copy of the existing services plan been provided to the person in charge of the
works?
Has consultation been undertaken between a site team member and the person
undertaking the excavation work to ensure they are aware of all possible service
affected by the works?
All workers involved in the works have sign off on their employer SWMS for the work to be
undertaken including; working with mobile plant, work around existing services, control
measures for potential collapse, access & egress, exclusion zones & other requirements.
Have defined communication protocols been implemented which may include 2 way
radio communication
Has all plant been inspected & risk assessment completed, approved for use on site and
operator daily log book completed.
Do other Permits need to be actioned with any associated works;
     Confined Space         Hot Works        Isolation

Permit Request:
This acknowledgement signifies a formal request to commence excavation and / or penetration works. As the person requesting this
permit, I hereby certify that:
  I am competent to coordinate this type of work in accordance with the Permit details;
  I shall undertake to implement all planned and necessary controls to ensure safe work methods; and
  I shall monitor the work hazards and control methods throughout the work.

Name:                                     Signature:                                        Date:                     Time:
Hutchinson Builders Forman / Supervisor Authorisation:
This Hutchinson Builders Forman / Supervisor Authorisation signify that the planning component of the Excavation & Penetration Permit
has been completed and that work is authorised to commence in accordance with the permit Request.

Name:                                     Signature:                                        Date:                     Time:
Section 4 – Implementation
Excavation Works Authorisation (Person in Direct Control):
The procedures, control measures and precautions appropriate for the safe execution of work have been implemented and the persons
required to work have been advised of and understand the requirements of the Excavation & Penetration Permit.

Name:                                     Signature:                                        Date:                     Time:

Constraints:          This Authorisation is valid until the following occurs, or the date and time shown:

                                                                                            Date:                     Time: