41-1 Form – Fill Out and Use This PDF

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)