Permit to Work – Excavation
Does this permit relate to another
permit
Yes (Provide details)
No
Location of Work
Description of work
Work / excavation
Method
Depth of excavation
Person / Company
carrying out work
Emergency Contact
Mobile
Estates Responsible Person
Details barriers / notices required
Detection methods / equipment
(inc ID no.’s)
Services
Duration of permit
Other
Checked
Comments
 X
High Voltage electricity
Medium & low voltage electricity
Gas
Water
IT cables
Telecommunications ducts / cables
Radio Warwick
Drains
Storm water
Land drains
Street lighting
Building Management Cables
HPHW / Stem services
Other (Detail)
I confirm that the services highlighted above have been checked and identified as necessary
Name
Date
Permit Cancellation (estates Dept.,)
Name
Date
.
In an Emergency, contact 22222 or 024765 22222
Time