S02 Trenching Permit - Fillable - .pdf

Attachment A

VA Boston Healthcare System Excavation & Trenching Permit

SIGNATURES:

Project COR Approval:

Engineering Mgr. or M&O Foreman Review:

Safety Review:

SECTION 1

To be completed prior to any trenching, excavation, digging or drilling and shall be maintained onsite.

Project: Project Number: Est. Start Date:

Est. End Date:

Requested by: COR/COS:

Name of CP for Trenching / Excavation (Please attach Qualifications and Activity Hazard Analysis (AHA) for excavation/trench work to be completed):

Work to be done (Attach a detailed sketch or drawing showing location, dimensions of work to be completed, grading plans for cut-and-fill work, adjacent buildings, roads, parking lots, utilities):

Nearest Building and/or Structure:

Length, Width and Depth “Maximum Dimensions (feet)”:

Requesting soil reuse as backfill? YES NO

Utility Review: The following utilities are present within the excavation area: (Check all that are applicable) Electrical Gas Storm Drain Telephone/Fiber Sanitary Sewer Water Steam Site Lighting Cameras/Security Underground Storage Tanks Other

Is the excavation/trenching within Wetlands or a Buffer Zone? YES NO

Excavation CP Signature and Date:

SECTION 2

To be completed prior to personnel entering excavations greater than 5 feet in depth.

Soil Determination using OSHA classification of soil, what is the classification type?

Solid Rock Type A Type B Type C

Please indication the protective system to be used (sloping/benching, shoring, shielding).

Note: When soil classification is identified as “Type A” or “Solid Rock”, only shoring or shielding or Professional Engineer designed systems can be used for protection. A Sloping/Benching system may only be used when classifying the soil as Type B or Type C. Refer to Appendix B of 29 CFR 1926, Subpart P for further information on protective systems designs.

Where workers enter an excavation greater than 5 feet in depth, are protective systems designed in accordance with 29 CFR 1926, Subpart P, Appendices B to E or designed by Professional Engineer [OSHA 29 CFR 1926.652(a)] Note: excavations in excess of 20 feet in depth must be designed by PE and sloping or benching systems cannot have an angle of repose steeper than 1 to 1 (45 degrees) as provided above.

Was an assessment conducted for a potential toxic, explosive, or oxygen deficient atmosphere where oxygen deficiency (atmospheres containing less than 19.5 percent oxygen) or a hazardous atmosphere exists or could reasonably be expected to exist.

Note: Internal combustion engine equipment is not allowed in an excavation without providing force air ventilation to lower the concentration to below OSHA PELs, providing sufficient oxygen levels, and atmospheric testing as necessary to ensure safe levels are maintained.

While the excavation is open, will underground installations be protected, supported or removed (Lockout/Tagout, supports built, etc.) as necessary to safeguard employees?

Excavation CP Signature and Date:

FINAL CHECK / PERMIT CLOSEOUT

Site has been properly backfilled.

Excess soil has been removed.

All safety and environmental concerns have been mitigated.

As-built drawings and utility line location results were verified in the field and the drawings were transmitted to the VA COR/COS. The Contractor shall photographically document all of the Section 2 and Final Check/Permit Closeout requirements and transmit them to the VA COR/COS. Attach with closeout submission. Upon completion of the excavation, signatures below on this permit indicate the excavation is completed. Signatures also indicate that the CP & COR\COS have walked the site and are in agreement that excavation is completed. This permit is now closed and the COR/COS, will retain this form in the project folder.

Excavation CP Signature and Date:

All Excavation & Trenching must be conducted in accordance with the following: OSHA 1926 Subpart P – Excavations

VHA Master Specifications, Section 01 35 26 - Safety Requirements, 1.18 Excavation and Trenches Contractors Site Safety Plan