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Get CA CAL/OSHA 41-3 2006-2024

State of California Department of Industrial Relations Division of Occupational Safety Health ACTIVITY NOTIFICATION FORM FOR HOLDERS OF ANNUAL PERMITS Buildings/Structures Scaffolding/Falsework Demolition Trenches/Excavations THIS FORM SHALL BE FAXED TO THE NEAREST DOSH OFFICE TO COMPLY WITH THE 8 CCR 341. 1 h. PLEASE DO NOT MAIL DUPLICATE NOTIFICATION AS A FOLLOW-UP TO FAX NOTIFICATION. FAX DATA FAXED TO DOSH FAX NO. DOSH DISTRICT OFFICE ON BY Company Name Field Phone Annual Permit Number Office Phone Issuing Region Issuing District Specific Activity Location Number of Employees Nearest Major Cross Street Starting Date City Anticipated Completion Date County High Voltage Lines in Proximity No Yes INSTRUCTIONS 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. Construction Building Wood Frame Structure Curtain Wall Type Steel Frame Precast Tiered Slip Form Concrete Depth Tilt-up Height Description Scaffolding Height Metal Wood Wood over 60 Feet Metal over 125 Feet Metal 125 Feet or Wood 60 Feet requires design by California Registered Civil Engineer Plans at Site. 1 h. PLEASE DO NOT MAIL DUPLICATE NOTIFICATION AS A FOLLOW-UP TO FAX NOTIFICATION* FAX DATA FAXED TO DOSH FAX NO. DOSH DISTRICT OFFICE ON BY Company Name Field Phone Annual Permit Number Office Phone Issuing Region Issuing District Specific Activity Location Number of Employees Nearest Major Cross Street Starting Date City Anticipated Completion Date County High Voltage Lines in Proximity No Yes INSTRUCTIONS 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. Construction Building Wood Frame Structure Curtain Wall Type Steel Frame Precast Tiered Slip Form Concrete Depth Tilt-up Height Description Scaffolding Height Metal Wood Wood over 60 Feet Metal over 125 Feet Metal 125 Feet or Wood 60 Feet requires design by California Registered Civil Engineer Plans at Site. See 8 CCR 1644 c 7 Falsework/Vertical Shoring Maximum Height Maximum Span Material See 8 CCR 1717 Demolition of Building Loader/Tractors Demolition Ball No* of Stories Clam Explosives Other Continued on back CAL/OSHA 41-3 Rev* 10/29/2006 Trenches/Excavations Depth Range Min/Max Ground Protection Method Shoring Width Range Min/Max Sloping Trench Shield Underground Services Alert USA Number Soil Analysis to be done Yes Total Length Professional Engineer NORTH 1-800-642-2444/SOUTH 1-800-422-4133 No If No You Must Slope 1. 5 to 1. Competent Person The holder of an Annual Permit who is notifying the District 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 of and will comply with the foregoing. .

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