WORK PERMIT FOR CIVIL WORK/ EXCAVATION

Permit Type: Construction/ Excavation

Exact Location: _________________________________________
Size of Excavation/ Construction (Approx)_________________________
Commencing: Date _________________ Time _______________
Expiry: Date _________________ Time _______________
Executing Department: _________________
Name of Person Giving Permission: ______________________________________ Signature: ___________
Name of Supervisory Authority: ______________________________________ Signature: ___________
This work permit is issued to:
Mr. : _____________________________
of M/s. : ________________________________________________________

The safety instructions on the reverse of this permit have also been explained in to details to:
Mr. __________________________ (In-charge of those who are going to perform the work)

I ____________________________ of M/s._____________________________________ give the undertaking that

I and my co-worker(s) will strictly follow the safety instructions while executing the above job. I have fully
understood the scope or work, the safety requirements and I have required safety equipments(s) needed for the job.

Date: __________________ Sign: _______________________

Name:______________________
(Incharge of the above job from)

I ____________________________ of __________________ (Department) will supervise to ensure that the above

named person and his co-worker(s) will strictly follow the safety instructions while executing the above job.

Date: __________________ Sign: _______________________

Name:______________________
(Incharge of the above job from)

I have over checked the safety arrangements and safety instructions given to:

Mr. ________________________ of M/s. ____________________________________________.

Date: ________________
Sign:______________________
Name: _____________________________ (Any Safety Committee Member).

SHE/2/CW 
 
Excavation Clearance:
1 Underground Power Cable : Existing/ Not existing Permission Given : Yes/ No.

2 Underground Telephone Cable : Existing/ Not existing Permission Given : Yes/ No.

3 Underground Drainage Line : Existing/ Not existing Permission Given : Yes/ No.

4 Underground Water Line : Existing/ Not existing Permission Given : Yes/ No.

5 Underground Computer Cable : Existing/ Not existing Permission Given : Yes/ No.

NOTE:
Excavation clearance is required for all excavations.
Obtaining the clearance is mandatory.
The above clearance is to be certified by all the concerned departments.
o Eg: EDP, Maintenance, etc.
The permission is to be taken at least five days (5 Days) before for the same.

(Signature of receiver) (Signature of issuer)

SHE/2/CW