Excavation Ground Disturbance Permit - Ottawa

Excavation Ground Disturbance Permit - Ottawa

EXCAVATION/GROUND DISTURBANCE PERMIT

Project Name:
Work performed by:*
Name of Company
Drawing #:
Location of excavation:*
Reason for excavation:*
Start date:*

MonthDayYear
Date
Permit Expires:*

MonthDayYear
Date
Person responsible for the excavation:*
Phone Number:*
Format: (000) 000-0000.

Utilities

Rows	Present in Excavation Area
Water
Sewer
Gas
Power
Fire Lines
Process Lines
Others

Comments:

Special Precautions/Requirements:

Rows	Check Those that Apply
% O2
Explosion testing
Gas/Fume testing
Standby person
Hand excavate at utility crossing
Grounding of tools
Barricades
Special clothing

Special Precautions/Requirements Other:
Comments on Special Precautions:
Craft Superintendent of Craft Excavating Name:*
Craft Superintendent of Craft Excavating Signature:*

Clear
Client Representative (if in an operating facility) Name:
Client Representative (if in an operating facility) Signature:

Clear
Excavation Competent Person Name:*
Excavation Competent Person Signature:*

Clear
HSE Representative Name:*
HSE Representative Signature:*

Clear
Competent Person Checklist
Stable RockType AType BType C

Rows	Yes	No	N/A
Have all procedural requirements been met and documented?
Is the excavation close to utilities, buildings, footings, pilings, source of vibration?
Have utilities, etc., been located?
Has a check for the previous excavations in the area been made?
Have adequate supplies of equipment, PPE, shoring material, signs, barricades, machinery, etc., been assured and checked?
Other obstructions/hazards:

If Other obstructions/hazards list them:
Slope will be:*
Slope Comments:*
Depth in feet.*
feet
Width in feet.*
Length in feet.*

Rows	Yes	No	N/A
Do vehicular and machinery operation patterns need to be changed?
Will water removal operations/equipment be needed?
Have trench boxes or trench shield been checked?

StairwayLaddersRamps
Note: Sloping/benching for excavations deeper than 20 feet must be designed by a PE.
Competant Person Signature:*

Clear
Date*

MonthDayYear
Date
What is your email?*
example@example.com (A copy of the final permit will be sent here.)
Should be Empty: