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epartment of Public Safety,

Department of Labor and

Workplace Develo

pment, and other 

applicable state and local

regulatory requirements.

The responsibility for the implementation, training and enforcement of this program rests ith

the!

"eneral #ontractor$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Pro&ect 'anager ( Site Superintendent$%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

The goal of this program is to provide a healthy and safe orking environment for everyone as

ell as to protect the site and the environment to the best of our ability. )f a conflict is identified

beteen the safety manuals of the general contractor, any sub*contractor, or the oner, the

most stringent requirement shall prevail.

+aard -ssessment * The "eneral #ontractor shall perform a haard assessment for this

pro&ect. During the assessment, the contractors/ shall identify potential areas of concern,

such as!

0 Sources of motion, such as machines and tools

1 +igh and lo temperatures

2 #hemical 34posures

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Dig Safe Notification Form

Before you dig…Contact Dig Safe

)n 'aine ( 'assachusetts ( 5e +ampshire ( 6hode )sland ( 7ermont .8888. 999/ DigSafe or 999/ 2::*;122

)n #onnecticut >/ ?11*::@@

)n 5e Aork State .................................................................................................. 9>>/ ?B1*;?B1

  * Long )sland ................................................................................................... 9>>/ 1;1*::9>

Site Superintendents

Please complete the required notification from belo, before contacting Dig Safe or other appropriate agency. -s

the site superintendent, you are required to make sure that the area has been pre*marked in hite, ith e4cavator 

companyCs name or logo before notification is made. The original form ith Dig Safe approval numbers/ must be

kept on the &ob site, ith a copy provided to the safety department.

1 The excavator is required to maintain all required marings!

6equest ile 5umber%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Date$ %%%%%%(%%%%%%(%%%%%%%%% 

Time$ %%%%%$%%%%% am(pm

State$ %%%%%%%%%%%%%%%%%%%%%%%% #ity or Ton$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Pro&ect 5ame$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

 -ddress(Location$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

)ntersecting Street$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Type of Work$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Depth of Work$ %%%%%%%%%% in eet/

34cavation #ompany$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

0 -ddress$

 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

0 Telephone$ %%%%%%%%/ %%%%%%%%% * %%%%%%%%%%%%% 

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=tilities notified by Dig Safe$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

=tilities notified by "eneral #ontractor and Ener$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Dig Safe is not responsible for utilities not installed or maintained by the above, such as those installed by the owner. The

General Contractor and Owner is not responsible for these.

6emarks$%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Dig Safe -pproval 5umber$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

Start Date$ %%%%%%(%%%%%%(%%%%%%%%% Start Time$ %%%%%$%%%%% am(pm 3mergency Aes ( 5o

5ame of 6equester$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Title$ %%%%%%%%%%%%%%%%%%%%%% 

#ompany$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 

The Dig Safe File number is good for thirty !"# days. $f your Dig Safe number has % will e&pire, then contact Dig Safe for a new

file number if you are planning to start or continue wor' after day !".

$n accordance with (assachusetts General )aw (G) Chapter *+, Section "# a person or company who violates any provision

of this section can be fined between -,"""."" st  offense# to -","""."" + nd  offense#.

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