Transcription of PROJECT ACTIVITY FORM 41-2 - California Department of ...
1 State of CaliforniaDepartment of Industrial RelationsDivision of Occupational Safety & HealthPROJECT ACTIVITY FORMB uildings/Structures, Scaffolding/Falsework, Demolition, Trenches/ExcavationsCompany Name:Annual Permit Number:Specific ACTIVITY Location:Nearest Major Cross Street:City:County:Field Phone:Office Phone:Number of Employees:Starting Date:Anticipated Completion Date:High Voltage Lines in Proximity? YesNoINSTRUCTIONS: The appropriate item(s) must be completed and signed by a person knowledgeable about the PROJECT for each ACTIVITY covered bya permit.
2 Please fill in or check off the blanks where : BuildingStructureType: Steel FrameTieredConcreteTilt-upWood FrameCurtain WallPrecast Slip Form DepthHeight Description:(See 8 CCR 1709-30: Appendix A Plate A-2a & b)Scaffolding:HeightMetalWoodWood over 60 FeetMetal over 125 FeetMetal > 125 Feet or Wood >60 Feet requires design by California Registered civil Engineer & Plans at Site.(See 8 CCR 1644(c)(7))Description:Falsework/Vertica l Shoring: Maximum HeightMaximum SpanMaterialDescription:(See 8 CCR 1717)Demolition Of: BuildingStructureHeightNo.
3 Of StoriesType: Steel FrameWood FrameConcreteDemolition BallClamExplosivesLoader/TractorsOther(S ee 8 CCR 1734 - 37)Trenches/Excavations:Depth Range(Min/Max) * CAL/OSHA 41-2 (Rev 10/29/2006)Width Range(Min/Max)Total LengthGround Protection Method:ShoringSlopingTrench ShieldProfessional EngineerUnderground Services Alert(USA) Number(NORTH 1-800-642-2444/SOUTH 1-800-422-4133)Soil Analysis to be done?YesNoIf No, You Must Slope to : Ground protection methods for excavations deeper than 20 feet must be designed by a Registered Professional 8 CCR , Appendix this a public works PROJECT ?
4 Yes No
