Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-155 - Safety standards for construction work › Part L - CRANES, RIGGING, AND PERSONNEL LIFTING › Section 296-155-56425 - Sample declaration form for hours of experience

Current through Register Vol. 24-14, July 15, 2024
DECLARATION OF
[enter
								employee/operator name here]
STATE OF WASHINGTON
)
) ss.
COUNTY OF enter county
)
I, enter name of operator here, declare as
								follows:
I am over the age of 18 and competent to testify
								herein. I make the statements herein based upon personal knowledge.
I declare under penalty of perjury that the
								following table (on page 2) lists my experience in operating and working with
								cranes:
The 5 Categories of Cranes and Their
								Types
Number of Hours of Actual Crane Operating
								Experience
Number of Hours of Crane Related
								Experience
(1)
Mobile Cranes
(a)
Lattice Boom Crawler Cranes (LBC)
300 tons and above
Hours
300 tons and above
Hours
Under 300 tons
Hours
Under 300 tons
Hours
(b)
Lattice Boom Truck Cranes (LBT)
300 tons and above
Hours
300 tons and above
Hours
Under 300 tons
Hours
Under 300 tons
Hours
Over 130 tons
Hours
Over 130 tons
Hours
(c)
Large Telescopic Boom Cranes (Swing Cab) (TLL)
								(including digger derricks)
Over 40 tons to 130 tons
Hours
Over 40 tons to 130 tons
Hours
40 tons and under
Hours
40 tons and under
Hours
Over 15 tons Hours
Over 15 tons Hours
(d)
Small Telescopic Boom Cranes (Fixed Cab) (TSS)
								(including digger derricks)
Over 5 tons to 15 tons
Hours
Over 5 tons to 15 tons
Hours
5 tons and under
Hours
5 tons and under
Hours
(2)
Articulating Boom Cranes
Hours
Hours
(3)
Tower Cranes
(a)
Hammerhead
Hours
Hours
(b)
Luffer
Hours
Hours
(c)
Self-Erecting
Hours
Hours
(4)
Overhead Cranes/Bridge and
								Gantry
(a)
Cab Operated
Hours
Hours
(b)
Pendant/Remote
Hours
Hours
(5)
Derricks
(not including digger
								derricks)
Hours
Hours
Hours of actual crane operating
								experience.
For all cranes: Time while the operator is at the controls
								of the crane; and/or has direct control of that crane; and/or a combination of
								operating hours within the same crane type. For mobile cranes: It also includes
								time while installing/removing boom sections, luffing boom, jib, extending and
								retracting outriggers/stabilizers, leveling crane, and replacing hoisting rope.
								For tower cranes: It includes time while jumping (increasing the height of the
								tower/mast).
Note:
Additional actual crane operator experience may
								account for crane related experience.
Hours of crane related experience:
Time as a signal person/bellman, oiler, crane mechanic, crane inspector, formal
								classroom training, crane simulator operation, and a combination of operating
								hours on other categories of cranes.
I declare under penalty of perjury that the
								foregoing is true and correct.
EXECUTED at City, Washington, this day of month,
								2011.
Signature of Operator
Statutory Authority:
					 RCW
					 49.17.010,
					 49.17.040,
					 49.17.050,
					 49.17.440,
					 49.17.060, and 29 C.F.R. 1926,
					 Subpart CC. 12-01-086, § 296-155-56425, filed 12/20/11, effective
					 2/1/12.