Form Var-1 - Application For Permanent Variance Page 2
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27.
Explain how the alternative safety and health measures described in item 6 will provide employment that is at least as safe
and healthful as that provided by the regulation(s) the applicant wants a variance from (e.g., the extra protective equipment will
compensate for restricted clearance, warning signs will alert employees to potential hazards)? (If more space is needed,
attach an additional sheet as Attachment 7).
8.
Photographs, blueprints, or other illustrative material documenting this application are attached as Attachment 8.
Applicant will need to submit six copies of the completed application and supporting material.
9.
Has applicant filed an appeal, or is one pending, with the Occupational Safety and Health Appeals Board relative
to the safety order for which the applicant is seeking a permanent variance?
Yes
No
Appeals Board Docket No.
10. Hearing location preference:
Sacramento
Oakland
Los Angeles
San Diego
11. a. Number of witnesses applicant will call at hearing:
b. Estimated time applicant will require to present case at hearing:
(Hearings typically last approximately 30 minutes)
12. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(Type or Print Name)
Signature of Applicant
Title
Company Name
If the applicant wishes to have a representative act on its behalf during the variance process, please complete this section (this
section must be signed by the applicant):
13. I,
, authorize the entity and/or person listed below to act on my
behalf in this permanent variance proceeding.
(Representative)
(Contact Person)
(Address)
(Telephone)
(City, State, Zip)
(Fax)
Signature of Applicant
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