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Get CA CAL/OSHA 41-3 1994

- State of California Department of Industrial Relations Division of Occupatonal Safety Health ACTIVITY NOTIFICATION FORM FOR HOLDERS OF ANNUAL PERMITS Scaffolding Falsework Trenches/Excavations 8 CCR 341. 1 f REQUIRES HOLDERS OF ANNUAL PERMITS TO PROVIDE NOTIFICATION TO THE DOSH OFFICE NEAREST THE PROJECT PRIOR TO COMMENCEMENT OF ANY WORK. THIS FORM IS PROVIDED FOR YOUR CONVENIENCE TO USE FOR SUCH NOTIFICATION. THIS FORM MAY BE FAXED TO THE NEAREST DOSH OFFICE TO COMPLY WITH THE ABOVE. PLEASE DO NOT MAIL DUPLICATE FAX DATA DOSH FAX NO. Anaheim FAXED TO Company Name 939-0815 BY UC Irvine Field Phone 2004-576393 Annual Permit Number Issuing Region DOSH DISTRICT OFFICE ON Office Phone 949 824-6982 Issuing District Specific Activity Location Number of Employees Nearest Major Cross Street Starting Date City County Anticipated Completion Date High Voltage Lines in Proximity Orange INSTRUCTIONS No Yes The appropriate item s must be completed and signed by a person knowledgeable about the project for each activity covered by a permit. - State of California Department of Industrial Relations Division of Occupatonal Safety Health ACTIVITY NOTIFICATION FORM FOR HOLDERS OF ANNUAL PERMITS Scaffolding Falsework Trenches/Excavations 8 CCR 341. 1 f REQUIRES HOLDERS OF ANNUAL PERMITS TO PROVIDE NOTIFICATION TO THE DOSH OFFICE NEAREST THE PROJECT PRIOR TO COMMENCEMENT OF ANY WORK. THIS FORM IS PROVIDED FOR YOUR CONVENIENCE TO USE FOR SUCH NOTIFICATION* THIS FORM MAY BE FAXED TO THE NEAREST DOSH OFFICE TO COMPLY WITH THE ABOVE* PLEASE DO NOT MAIL DUPLICATE FAX DATA DOSH FAX NO. Anaheim FAXED TO Company Name 939-0815 BY UC Irvine Field Phone 2004-576393 Annual Permit Number Issuing Region DOSH DISTRICT OFFICE ON Office Phone 949 824-6982 Issuing District Specific Activity Location Number of Employees Nearest Major Cross Street Starting Date City County Anticipated Completion Date High Voltage Lines in Proximity Orange INSTRUCTIONS No Yes The appropriate item s must be completed and signed by a person knowledgeable about the project for each activity covered by a permit. Please fill in or check off the blanks where appropriate. Height Wood Metal Wood over 60 Feet Metal over 125 Feet Metal 1 25 Feet or Wood 60 Feet requires design by California Registered Civil Engineer Plans at Site. See 8 CCR 1644 c 7 Description FalseworklVertical Shoring Maximum Height Maximum Span Material See 8 CCR 1717 Trenches/Excavations Ground Protection Method Depth Range Min/Max Shoring Sloping Width Range Min/Max Professional Engineer Trench Shield NORTH 1-800-642-2444/SOUTH 1-800-422-4133 Underground Services Alert USA Number Soil Analysis to be done Total Length If No You Must Slope 1. 5 to 1. Competent Person The holder of an Annual Permit who is notifying the Distrtict of the commencement of a Trench and/or Excavation project shall designate a competent person in accordance with the requirements of 8 CCR Section 1504 1541 and 1541. 1. See 8 CCR 1541. 1 Appendix F* I hereby certify that to the best of my knowledge the above information and assertions are true and correct and that I/the applicant have knowledge ofand will comply with the foregoing. .

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