CA 41-1 PDF Details

In the sphere of industrial endeavors within California, ensuring the safety and healthfulness of work environments, particularly in fields that inherently carry substantial risk, is not just beneficial but mandated by law. The State of California Department of Industrial Relations, through its Division of Occupational Safety & Health (DOSH), administers the enforcement of such regulations via tools like the Permit Application Form (41-1). This form is essential for activities involving buildings/structures, scaffolding/falsework, demolition, trenches/excavations, and more, as outlined in sections 6500, 6501, and 6502 of the California Labor Code. It necessitates that employers or their representatives, seeking to undertake such activities, furnish detailed information for DOSH's review. This rigorous process aims to evaluate and ascertain the prospective safety of the workplace concerned. Moreover, the issuance of a permit is contingent upon the demonstration of a workplace that is to be, or already is, safe and healthful for its employees. The form spans various permit types, including but not limited to, annual permits, single or multiple project permits across a range of specific activities from trench/excavation work to scaffolding and structural steel erection. Furthermore, conditions such as the implementation of a written Injury and Illness Prevention Program, designation of competent persons for certain tasks, and adherence to safety orders are stipulated to enhance workplace safety. Failure to comply with the terms may lead to denial or the revocation of the permit, against which employers have the right to appeal. This comprehensive approach underscores California's stringent measures towards ensuring the welfare of those in the industrial sector.

QuestionAnswer
Form Name41-1 Form
Form Length1 pages
Fillable?Yes
Fillable fields47
Avg. time to fill out9 min 43 sec
Other namescalifornia department trenches, cal osha 41 1r, department permit trenches online, ca dir permit application form

Form Preview Example

State of California

Department of Industrial Relations

Division of Occupational Safety & Health

Clear Fields

Print Form

PERMIT APPLICATION FORM

Buildings/Structures, Scaffolding/Falsework, Demolition, Trenches/Excavations

Section 6500, 6501 and 6502 of the California Labor Code require that certain activities, which by their nature involve substantial risk of injury, may not be performed without a permit issued by DOSH. The Labor Code requires that the applicant supply, and that the Division review, information necessary to evaluate the safety of the workplace subject to permit requirements. A permit will not be issued until evidence has been demonstrated that the place of employment will be safe and healthful.

Employer:

 

___________________________________________

Employer’s Rep.:

____________________________________________

 

Address:

 

___________________________________________

Title & Phone No.:

____________________________________________

 

 

 

___________________________________________

State Contractor’s License No.:

________________________________

 

Phone:

 

___________________________________________

Fax/Email:

________________________________________________

 

 

 

 

 

Check Applicable Items

 

Applicant refers to contractor or knowledgeable representative in a

 

Applicant is:

 

 

 

position of authority and responsibility for the activity covered by this

 

 

 

 

 

 

 

permit.

 

Project Administrator

 

 

 

 

 

 

 

 

 

 

 

Specialty Contractor

 

 

 

 

 

 

 

Type:

_______________________________________

 

☐ Other:

_______________________________________

 

 

 

 

 

 

 

 

Type of Permit Sought

 

 

 

 

 

 

Annual Permit

 

Single / Multiple Project Permit

 

 

T1 – Trench/Excavation

 

(Check one. Multiple allowed if projects covered are similar in all

 

 

S4 – Scaffold/Falsework/Vertical Shoring

 

important aspects, work is performed by the same employer and

 

 

D3 – Demolition

 

information concerning each project is provided)

 

 

SE – Structural Steel Erection

 

T1 – Trench/Excavation

 

 

MD – Metal Decking

 

C2 – Construction of Building/Structure

 

 

CW – Curtain Walls/Precast Panels/Stone Fascia

 

D3 – Demolition

 

 

 

RC – Reinforced Concrete Structures/Concrete Decks

 

S4 – Scaffold/Falsework/Vertical Shoring

 

 

SF – Structural Framing/Roof Framing/

 

Is this a public works project? ☐ Yes ☐ No

 

 

 

Panelized Roof Systems

 

Temporary Permit (Plan Check Only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any permit based on this application is issued with the understanding that the applicant has knowledge of occupational safety and health orders applicable to the project(s) described in the application and attachments and that the applicant and supervising personnel will take special care to ensure compliance with safety orders reviewed with the applicant by the Division in the application process.

Issuance of the permit is also conditioned upon the following:

1)Upon initiation of any new project not described in the application, the holder of an Annual Permit will provide the Division with a completed Activity Notification Form for Holders of Annual Permits describing the new project prior to the start of work, preferably at least one week in advance of the start-up date.

2)The applicant has implemented a written Injury and Illness Prevention Program and Code of Safe Practices which meet the requirements of 8 CCR Sections 1509 & 3203.

3)The Division will be notified of significant changes in information provided with the application if such changes might affect the safety of the activity.

4)The applicant for a Trench and/or Excavation Permit shall designate a competent person in accordance with the requirements of 8 CCR 1504, 1541 and 1541.1 for each Trench and/or Excavation project.

5)The applicant understands that under the permit program DOSH schedules routine inspections by authorized personnel for the purpose of verifying that holders of Annual or Activity Permits are meeting their obligation to provide a safe work place for their employees. The Division reserves the right to revoke or suspend a permit if it is unable to promptly verify compliance with the terms and conditions of the permit and its issuance.

6)The applicant understands that failure to comply with any of the above listed conditions for obtaining a permit could result in denial, suspension, or the revocation of the permit. Employers may appeal these actions to the Director of the Department of Industrial Relations (California Labor Code Section 6500 at. Seq. and 8 CCR 341)

Is the applicant conducting any activities to be covered by this Permit Application Form, as a partnership or joint venture with any other persons or corporations conducting activities

requiring permits?

☐ Yes

☐No

 

 

If yes, give details:

__________________________________________________________

 

Have any permits for any project to be covered by this permit application previously been applied for or obtained? ☐Yes

☐No

If yes, when:

 

______________________________

 

From what district office:

______________________________

 

In whose name:

 

______________________________

 

 

 

 

DIVISION USE ONLY

 

I hereby certify that to the best of my knowledge all information and assertions made on the Permit Application and/or

Fee _________________

 

Activity Notification Form are true and correct and that I/the applicant have knowledge of and will comply with the

 

foregoing.

 

 

 

 

 

 

 

 

Paid _________________

 

 

 

 

Approved _____________

 

Signature:

____________________________________________________________________________________

Conference

_________

 

Title:

____________________________________________________________________________________

Other

_____________

 

Date:

____________________________________________________________________________________

 

 

 

 

 

 

 

CAL/OSHA 41-1 (11/29/2022)

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ca dir permit app form gaps to fill in

Enter the required data in the area T TrenchExcavation S, Panelized Roof Systems, T TrenchExcavation C, Temporary Permit Plan Check Only, Any permit based on this, Issuance of the permit is also, Upon initiation of any new, The applicant has implemented a, The Division will be notified of, The applicant for a Trench andor, The applicant understands that, The applicant understands that, Is the applicant conducting any, Have any permits for any project, and From what district office.

ca dir permit app form T  TrenchExcavation  S, Panelized Roof Systems, T  TrenchExcavation  C, Temporary Permit Plan Check Only, Any permit based on this, Issuance of the permit is also, Upon initiation of any new, The applicant has implemented a, The Division will be notified of, The applicant for a Trench andor, The applicant understands that, The applicant understands that, Is the applicant conducting any, Have any permits for any project, and From what district office fields to fill

In the Fee, Paid, Approved, Conference, Other, I hereby certify that to the best, Signature, Title, Date, and CALOSHA area, emphasize the necessary information.

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