Form CAL/OSHA 41-3 at a glance
What it is: Form CAL/OSHA 41-3 is the Activity Notification Form for Holders of Annual Permits for Buildings/Structures, Scaffolding/Falsework, Demolition, Trenches/Excavations.
Who signs: The appropriate item(s) must be completed and signed by a person knowledgeable about the project for each activity covered by a permit.
A filled-in Form CAL/OSHA 41-3 example: a foreman fills in a trench
How to fill out Form CAL/OSHA 41-3, box by box
Fax data
Under FAX DATA, fill in FAXED TO, DOSH DISTRICT OFFICE ON, DOSH FAX NO. and BY.
Company, permit and location
Enter the Company Name, Annual Permit Number, Issuing Region, Issuing District, Field Phone and Office Phone.
Enter the Specific Activity Location, Nearest Major Cross Street, City, County, Number of Employees, Starting Date and Anticipated Completion Date.
High voltage lines and public works
Mark Yes or No for High Voltage Lines in Proximity? and for Is this a public works project?
Construction
Under Construction, mark Building or Structure and the Type: Steel Frame, Tiered, Concrete, Tilt-up, Wood Frame, Curtain Wall, Precast or Slip Form, and enter the Depth, Height and Description.
Scaffolding
Under Scaffolding, enter the Height, mark Metal, Wood, Wood over 60 Feet or Metal over 125 Feet, and enter the Description.
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
Under Falsework/Vertical Shoring, enter the Maximum Height, Maximum Span, Material and Description (See 8 CCR 1717).
Demolition
Under Demolition of, mark Building or Structure, enter the Height and No. of Stories, and mark Steel Frame, Wood Frame, Concrete, Demolition Ball, Clam, Explosives, Loader/Tractors or Other, and enter the Other type.
Trenches and ground protection
Under Trenches/Excavations, enter the Depth Range (Min/Max), Width Range (Min/Max) and Total Length.
Under Ground Protection Method, fill in Shoring, Sloping, Trench Shield or Professional Engineer.
Ground protection methods for excavations deeper than 20 feet must be designed by a Registered Professional Engineer. See 8 CCR 1541.1, Appendix F.
Enter the Underground Services Alert (USA) Number (NORTH 1-800-642-2444/SOUTH 1-800-422-4133).
Mark Yes or No for Soil Analysis to be done? If No, You Must Slope 1.5 to 1.
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, and enter the Description.
Certifying and signing
By signing you certify that to the best of your knowledge the information and assertions are true and correct and that you, the applicant, have knowledge of and will comply with the information and assertions.
Enter the Name (Please Type or Print), then SIGN on the Signature line and enter the Title and Date.
More rules for Form CAL/OSHA 41-3
Please fill in or check off the blanks where appropriate.
Common questions about Form CAL/OSHA 41-3
Where do I file it?
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.
Sources
[1] Form CAL/OSHA 41-3 (Rev. 11/1/2021), Activity Notification Form for Holders of Annual Permits, California Division of Occupational Safety and Health (the Official source link on this page).