3. Mobile Crane Permit 08-2017.docx

DEPARTMENT OF VETERANS AFFAIRS

CRANE PERMIT

A Crane Permit including all supporting documents must be submitted and approved prior to any of the following types of lifts. Permits must be at the lift site until lift is complete. Permits must be reissued if conditions (equipment, weather, and/or ground) or scope of work has changed.

|_|Lifting load over building, process, etc.

A. GENERAL

Originator:

Project Manager:

Start Date/Time:

Finish Date/Time:

Crane Owner:

Crane Lift Location (Area/Building):

Contractor Safety Representative:

Phone:

Competent Person (Crane Operator):

Phone:

Competent Person (Rigging):

Phone:

B. LIFT DATA

Estimated Weight: Lbs. Actual Weight: Lbs.

1b. Total load weight as a percentage of rated load capacity of crane from load chart: %

2. Rigging weight:

2a. Main Hoist Block, Auxiliary Boom Head / Headache Ball:

Total Block Weight: Lbs.

2b. Slings, Shackles, Hardware (list all used):

Total Rigging Weight: Lbs.

2c. Jib Weight Allowance: Lbs.

Check One: Erected (not used): |_| Erected (in use): |_| Jib Stowed (on boom): |_|

3. Total Lift Weight:

3a. On Sling: 1a + 2b = Lbs.

3b. On Crane: 1a + 2a + 2b + 2c = Lbs. Total Lift Weight: Lbs Example Calculation:

Example Calculation:

*Note: Contingency = Total Lift Weight Must be =/< 90% of Load Chart Capacity

Maximum Height of Crane Boom / Extension Tip Feet |_|Elevation drawing showing load height relation to crane and any obstructions is attached |_|Is maximum height of Crane Boom tip within Permit Limits Granted by Airport / FAA |_| Yes |_| No |_|Additional FAA Approval Is Required For Any Work Outside Current Pfizer Lift Zones (See Appendix A & B) Current Permit Height: Zone #

|_|Plan view of load location and crane orientation attached

C.

CRANE DATA & LIFT SET UP

1. Crane Manufacturer:

Crane Manufacturer: Size: Model Number:

Date of Last Annual Inspection: Inspected by:

2. |_|Verify manufacturer's load chart indicates lifting capacity at stipulated load radius and boom lengths.

Note: If boom length and/or radius is between the stipulated or posted value on the load chart select the next lesser rating capacity. The next lesser rating capacity may be the next longer or shorter boom length.

4. Counterweight:

|_|Yes Total Weight Lbs. Total Crane Weight Lbs.

5. Jib / Extension: Jib Length (as extension): Jib Offset:

6. Main Load Block:

Capacity Size: Ton # Sheaves: Weight Lbs.

7. Auxiliary Boom Head/Ball:

Capacity Size: Ton # Sheaves: Weight Lbs.

8. Outriggers, Pads, and Tires:

|_|An engineering review has determined underground utilities and structures are not at risk |_|Outriggers Fully Extended and Set Check One: Track |_| Tires |_| |_|Total Outrigger Bearing Pressure has been Calculated and Soil Type, Ground, and Pavement has Capacity to Support the Total Imposed Load |_|Outrigger Mats are Sized to Reduce Soil Bearing Pressure to Safe PSI Levels |_| Construction Manager has provided site drawing with crane set up zone identified.

|_| Pre-surveying meeting occurred with Surveyor, SME’s, CM, & Crane Firm (Operator attendance preferred) |_| CM escorted utility surveyor and maintained accuracy and potential problematic areas on sketch & provided/discussed with crane firm.

|_| Post survey meeting occurred with Surveyor, SME’s, CM, & Crane Operator on morning of work commencement |_| Ground Penetrating Radar (GPR) Conducted (recommend <2 weeks prior).

|_| Radio Frequency Testing Conducted (recommend <2 weeks prior) |_| All utilities marked per APW uniform color codes.

D. RIGGING DATA

1. Sling(s)/ Shackles

Type of Sling: Length: Capacity (per leg): Basket / Straight / Choker:

Size: Capacity (ea.)

Spreader Bar: Feet Lbs. Verify MFG/Eng. Stamp:

E. LIFT COMPUTATION

Minimum Boom Angle:

Maximum Boom Length:

Maximum Lift Radius:

Note: Cranes equipped with computers indicating boom length, angle, and radius are safety devices only and should not be used in place of the operator's responsibility to actually determine the measurements required to calculate a safe lift.

Note: Accessories, Crane Capacity, Parts of Line and Rope Capacity, and the working quadrant of the crane should be considered when calculating Net Crane Capacities.

1. Crane Capacity: (Load Chart Capacity) Lbs.

2. Net Crane Capacity: (Load Chart Capacity - Block, Rigging, and Accessory Weights) = Lbs.

3. Load orientation prior to lift: |_| Front |_| Side |_| Rear

4. Swing orientation relative to crane: |_| Front |_| Side |_| Rear

F. APPROVALS

The Contractor, Rigger, and Crane Operator are the competent persons responsible for the safe execution of the lift(s). Execution of the lift shall be in accordance with OSHA regulations.

COMPLETE CHECKLIST BELOW TO ENSURE A SAFE LIFT IS PLANNED

|_|Crane pick location has been located on map (see appendix A & B) |_|The load weight is confirmed known |_|The load hook is directly over the load center of gravity |_|Boom angle, boom length, lift radius, and the crane capacity are known |_|Outrigger pads are fully extended and blocking is sufficient for the load |_|Tires are clear of the ground and the crane is level |_|All obstacles and obstructions have been identified |_|Lifts in close proximity to power transmission lines shall meet OSHA 29 CFR 1926.550, MIOSHA R 408.11936, and applicable ANSI B30.5 safety standards |_|A signal method has been determined between the crane operator and the signalman |_|An individual has been designated to observe for obstructions and unauthorized personnel |_|The crane operator meets MIOSHA qualifications requirements to operate the crane |_|Crane boom is equipped with airport safety flag and/or beacon light |_|Swing radius has been barricaded and access is limited to authorized personnel |_|Crane lift site has traffic and pedestrian controls in place

|_|Verify a "competent person" has inspected prior to use and during use, all slings, fastenings, and attachments for damage or defects. Damaged or defective equipment shall be immediately removed from service.

|_|Verify a "competent person" has inspected all crane equipment and machinery prior to use and during use to ensure it is in safe operating condition. Any deficiencies shall be repaired prior to continued use.

|_|Verify the crane is in compliance with Federal and State regulations requiring frequent, periodic, and annual inspections. A thorough annual inspection has been made by a competent person, government, or private party recognized by the U.S. Department of Labor.

Wind Speed: Crane is equipped with anemometer: |_| Yes |_| No Lifts are not allowed with wind speed in excess of: MPH Wind Speed at time of lift: MPH

Construction Manager:

Name: ______________________ Signature: _______________________________ Date: ________

Contractor Representative:

Name: ______________________ Signature: _______________________________ Date: _________

Certified Crane Operator:

Name: ______________________ Signature: _______________________________ Date: ________

Qualified Rigger:

Name: ______________________ Signature: _______________________________ Date: ________

Certified Signal Person Name: ______________________ Signature: _______________________________ Date: ________

VA Representative:

Name: ______________________ Signature: _______________________________ Date: ________

Safety Office Approval:

Name: ______________________ Signature: _______________________________ Date: _________ image2.wmf oleObject2.bin image1.wmf oleObject1.bin