Mobile Cranes/Derricks Worksheet for Construction Industry



Certifier’s Reference # FORMTEXT ?????Worksheet provided to site: (person’s name) FORMTEXT ?????Department of Labor and IndustriesDivision of Occupational Safety & HealthPO Box 44650 Mobile Cranes/Derricks Worksheet for Construction IndustryOlympia WA 98504-4650 Email: LNICranes@Lni.Office: (360) 902-4943Fax: (360) 902-5438Name of Owner (Not Lessee) FORMTEXT ?????Permanent Sticker ID # FORMTEXT ?????Inspection Exp. Date FORMTEXT ?????Proof Load Test Exp. Date FORMTEXT ?????Mailing Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip+4 FORMTEXT ?????Phone Number FORMTEXT ?????Owner’s Email Address: FORMTEXT ?????Is this Crane Leased or Rented FORMCHECKBOX Yes FORMCHECKBOX No If Yes, Write Lessee’s Name and Address below: FORMCHECKBOX Send Certification to this address FORMTEXT ?????Description: FORMCHECKBOX Lattice Boom FORMCHECKBOX Hydraulic Boom FORMCHECKBOX Articulating Boom FORMCHECKBOX Derrick FORMCHECKBOX Other FORMTEXT ?????Owner’s ID # FORMTEXT ?????Manufacturer FORMTEXT ?????Max Rated Capacity in Lbs FORMTEXT ?????Model Number FORMTEXT ?????Serial Number FORMTEXT ?????Hr Mtr. Reading FORMTEXT ?????Boom Length at Time of Inspection: FORMTEXT ?????Jib Length at time of Inspection: FORMTEXT ?????If Derrick, state type, Breast, Stiff-leg, A-Frame, etc. FORMTEXT ?????Wire RopeNo. PartsDiameterNo. StrandsWires per StrandRotation Res.(Yes/No)Breaking StrengthMain Hoist FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Whip FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Boom FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Boom Pendants FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????The following items must be inspected where applicable: (if not applicable, so indicate)AcceptN/AAcceptN/Aa) Chassis, Tires, Steering FORMTEXT ????? FORMTEXT ?????p) Ladders, Hand Holds FORMTEXT ????? FORMTEXT ?????b) Fluid Leaks & Fluid Levels FORMTEXT ????? FORMTEXT ?????q) Brakes, Hoist, Boom, Turret, etc. FORMTEXT ????? FORMTEXT ?????c) Guards, Rails, Windows FORMTEXT ????? FORMTEXT ?????r) Load Charts and Operator’s Manual FORMTEXT ????? FORMTEXT ?????d) Outriggers, Stabilizers, Pads FORMTEXT ????? FORMTEXT ?????s) Housekeeping / Maint. & Insp. Records FORMTEXT ????? FORMTEXT ?????e) Rotation Bearing / Swing Lock FORMTEXT ????? FORMTEXT ?????t) Boom including Wear Pads if applicable FORMTEXT ????? FORMTEXT ?????f) Hook Rollers and Load Rollers FORMTEXT ????? FORMTEXT ?????u) Boom Extensions, Jib FORMTEXT ????? FORMTEXT ?????g) Counterweights per Manufacturer FORMTEXT ????? FORMTEXT ?????v) Structural Welds FORMTEXT ????? FORMTEXT ?????h) Data Plates / Warning Signs, Decals FORMTEXT ????? FORMTEXT ?????w) Boom and Hoist Sheaves FORMTEXT ????? FORMTEXT ?????i) Controls / Functions / Labeled FORMTEXT ????? FORMTEXT ?????x) Pennant Bars / Cables and Links FORMTEXT ????? FORMTEXT ?????j) Lights / Signals / Horn FORMTEXT ????? FORMTEXT ?????y) Operational Aids / Safety Devices FORMTEXT ????? FORMTEXT ?????k) Gauges working FORMTEXT ????? FORMTEXT ?????z) Anti-Two-Block Device FORMTEXT ????? FORMTEXT ?????l) Backup Alarm FORMTEXT ????? FORMTEXT ?????aa) Limit Switches FORMTEXT ????? FORMTEXT ?????m) Fire Extinguisher (10BC min.) FORMTEXT ????? FORMTEXT ?????bb) Hook(s) FORMTEXT ????? FORMTEXT ?????n) Electrical Equipment FORMTEXT ????? FORMTEXT ?????cc) Wire Rope Beckets, Pins FORMTEXT ????? FORMTEXT ?????o) Hydraulic Systems FORMTEXT ????? FORMTEXT ?????dd) Hoist Drum FORMTEXT ????? FORMTEXT ?????FREELY SUSPENDED PROOF LOAD TEST REQUIRED: Proof load test for cranes must be based on manufacturer’s load ratings and must be at least 100% but not exceeding 110% of the rated capacity. Derricks must be proof load tested in excess of safe working load: for capacities up to 20 tons = proof load 25% in excess; 20 tons to 50 tons = Proof -load 5 tons in excess; over 50 tons = 10% in excess.Main orWhipBoom Length (Feet)Radius(Feet)Boom Angle(Degrees)Rated Capacity (Lbs)Total Deductions (Lbs)Net Rated Capacity (Lbs)Test Load (Lbs)Load Test (% )Crane Configuration &Test Range FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Was This Crane Tested on Rubber? Yes FORMCHECKBOX (List parameters below) No FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Means of Application of Proof Load Test see WAC 296-155-53200(7)(f) FORMCHECKBOX Certified Test Weights FORMCHECKBOX Weights Using Currently Calibrated Scale(“Known weights” is not acceptable)Remarks: Additional sheets attached? Yes FORMCHECKBOX No FORMCHECKBOX Crane Operator’s Name (please print) FORMTEXT ????? FORMCHECKBOX I hereby certify the above tests and/or examinations have been conducted in accordance with the Washington State Safety Standards for Construction Operations, WAC 296-155. A copy of this worksheet will be used as a temporary certificate until the annual certification is issued. This temporary certificate is valid for 30 days after the date of this inspectionDate FORMTEXT ?????Accredited Certifier’s Name (please print) FORMTEXT ?????Accredited Certifier’s ID # FORMTEXT ?????Certifier’s Phone # FORMTEXT ?????Address FORMTEXT ?????Signature of Accredited Certifier FORMTEXT ????? FILLIN "Please type your name" \* MERGEFORMAT ................
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