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| Question | Answer |
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| Form Name | Form Cauosha 41 3 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | calosha 41 3 form, ca osha 41 3, osha notification form, osha 41 3 |
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
FAX DATA: FAXED TO |
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DOSH DISTRICT OFFICE ON |
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DOSH FAX NO. ( |
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BY |
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Company Name: |
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Field Phone: |
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Annual Permit Number: |
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Office Phone: |
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Issuing Region: |
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Issuing District: |
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Specific Activity Location: |
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Number of Employees: |
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Nearest Major Cross Street: |
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Starting Date: |
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City: |
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Anticipated Completion Date: |
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County: |
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High Voltage Lines in Proximity? No |
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Yes |
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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 |
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Structure |
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Type:Steel Frame |
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Tiered |
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Concrete |
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Wood Frame |
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Curtain Wall |
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Precast |
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Slip Form |
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Depth |
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Height |
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Description: |
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Scaffolding: HeightMetalWoodWood 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))
Description:
Falsework/Vertical Shoring: Maximum Height |
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Maximum Span |
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Material |
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Description: |
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(See 8 CCR 1717) |
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Demolition of: Building |
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Structure |
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Height |
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No. of Stories |
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Type:Steel Frame |
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Wood Frame |
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Concrete |
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Demolition Ball |
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Clam |
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Explosives |
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Loader/Tractors |
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Other |
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Continued on back |
CAL/OSHA |
Trenches/Excavations: Depth Range (Min/Max) |
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Width Range (Min/Max) |
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Total Length |
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Ground Protection Method: Shoring |
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Sloping |
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Trench Shield |
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Professional Engineer |
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Underground ServicesAlert (USA) Number |
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(NORTH |
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Soil Analysis to be done? Yes |
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No |
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If No, You Must Slope 1.5 to 1. |
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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.
Description:
*Ground protection methods for excavations deeper than 20 feet must be designed by a Registered Professional Engineer. 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.
Name:
(Please Type or Print)
Signature:
Title:
Date:
CAL/OSHA