GROUND DISTURBANCE PERMIT
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Operator
*
First Name
Last Name
Operator Email
*
example@example.com
Site Superintendent
*
Alex Osbelt
Andre Lomas
Brian Bonner
Gabe Lamarche
Jeff Glowatsky
Nevil Stow
Peter Fordham
Other
Site Superintendent Email
*
example@example.com
Work Site
*
Alexander Hotel
Black Swift Lodge
Grey Wolf Lodge
MLV 1100/1200
Mountain Lynx Lodge
Multiple Sites
RV
Spring Creek Gate Road Extension
TMV 900/1000
Company
*
Adlers Fire Stop
Alpine Overhead Doors
Big Horn Sheet Metal
Bow Valley Safety
Bow-Cor Welding
Canglass
Canmore West Eavestrough
Cascade Mechanical
Competition Concrete
Convergint Technologies
Diamond Fireplaces
Downer Contracting
Dust Be Gone
Enlightened Organizing
Gallant Insulation
Guisti
Flipped Canoe Cribbing Inc.
Hellbent Geothermal
Henry's Electric
Heritage Decking
Iceline Waterproofing
KCP Energy
Legacy kitchens
Lomaw Contracting
Master Pools
McCool Construction YYC
Men in Kilts
Mountain Prism Painting
Northstar Fire Protection
Old West Flooring
Oskar
Peter's Exteriors
Primary Engineering
Prime Drywall
Procat Contracting Ltd.
Rgo
S2S Electric
SCMV - Construction
SCMV - Client Care
SCMV - RV/Maintenance
Set in Stone
Thompson Drilling
Tristar Woodworks
Wayco Electric
Woodpecker European Timber Framing
Other
Method of Excavation
*
Please Select
Machine
Hydrovac
Hand Digging
Other
Depth of Excavation
*
Please Select
0-1 meter
1-3 meter
>3 meter
Type of Excavation
*
Please Select
Open Excavation
Trenching
Landscaping for Trees or Shrubs
Other
Engineering Controls
1. Have all utilities been marked and identified within proposed excavation area?
*
YES
NO
2. Does the operator and workers have a copy of the locates and/or been shown where existing services are?
*
YES
NO
3. Has soil been classified prior to excavation taking place?
*
YES
NO
Confirm material type being excavated
*
4. Are protective systems required?
*
YES
NO
Confirm protective systems during the excavation process
*
5. Are all employees protected from cave-ins when entering and exiting the excavation?
*
YES
NO
6. Have hazardous objects around the excavation been removed or supported?
*
YES
NO
7. Is all spoil maintained at least 1 meter back from the edge of the excavation?
*
YES
NO
8. Are ladders used for access and egress?
*
YES
NO
8b. Are they placed as close as possible to the work area?
*
YES
NO
9. Are employees protected from loose materials or tools which could fall into the trench?
*
YES
NO
10. Is the excavation free of standing or seeping water?
*
YES
NO
11. Is there evidence of cracking or sloughing of soil since the last inspection?
*
YES
NO
12. Is heavy equipment kept away from the edge of the excavation?
*
YES
NO
Administrative Controls
13.Competent person trained in Ground Disturbance 201?
*
YES
NO
14. Has the Excavator Operator and workers inspected the excavation prior to start of each work period?
*
YES
NO
15. Have all affected parties been notified of excavation works?
*
YES
NO
16. Have all the work plans been discussed with all workers and the Site Superintendent?
*
YES
NO
PPE Controls
17. Are employees wearing the proper safety equipment?
*
YES
NO
18. Are any changed conditions properly noted?
*
YES
NO
Additional comments on safety:
Excavator Operator Signature:
*
Back
Submit
Next
PERMIT APPROVED?
*
Yes
No
Comments
Site Superintendent Signature:
*
Site Superintendent Signature Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: