Wieland-Davco Health and Safety Program January 2007 WIELAND-DAVCO CORPORATION CRITICAL LIFT PERMIT Section 1: Approvals and

Documentation A. Identification Subcontract Number: Lift Identification Name: Date of Lift: Lift Description: B. Approva ! "#i$nat%re Re&%ired' Subcontractor: Subcontractor Lift Supervisor:
(This individual must be present during the lift)

Location:

Time:

Date: Date Date: Date: Date: Date Date:

Project Manager: D! Superintendent: "perator: #ngineering:

(If Engineering Designs are used)

D! Safet$ %ep&: C. Attac()ent! 1& '& )& *& +& "perator !ertifications !apacit$ !ertificates and Inspection %eports for all Lifting #(uipment Inspection %eports for all %igging #(uipment %igging Diagram ,ree -od$ Diagram

Page 1 of +

Wieland-Davco Health and Safety Program January 2007 Section ' : Pre.Lift Planning A. Pre-Lift C(ec* i!t /Initials0
1es No

1& '& )& *& +& 6& 7& 8& 9& 1:& 11& 1'& 1)& 1*& 1+& 16& 17&

2as an inventor$ of e(uipment been done3 2ave 4eat5er conditions been considered3 2ave t5e general safet$ precautions been revie4ed3 2ave t5e electrical safet$ procedures been revie4ed3 2ave t5e safe rigging practices been implemented3 2ave t5e safet$ precautions been revie4ed3 2as a met5od of attac5ment and 5andling been determined3 Are all lifting lugs engineered to specifications3 2as t5e matting been inspected and approved3 2as t5e stabilit$ of t5e ground been assured3 Is a tag line going to be used3 2ave disconnecting;connecting means been developed3 2as t5e orientation of e(uipment been confirmed3 Is surve$ e(uipment re(uired3 Is a Pre.Lift Meeting planned3 Is a total 4eig5t belo4 7+< of capacit$3 Are all re(uired approvals signed3

Page ' of +

Wieland-Davco Health and Safety Program January 2007

Section ): Load and !apacit$ !alculations A. Wei$(t of E&%ip)ent + Live Load 1& '& )& #(uipment !ondition: eig5t of #(uipment #mpt$ eig5t of Attac5ments: a& Platforms and Ladders b& Piping and Accessories c& Li(uids Inside d& Dirt and Debris e& Internal Tra$s or Liners Total eig5t of #(uipment Ne4 =sed Lbs Lbs Lbs Lbs Lbs Lbs Lbs

*& B.

Tota Load Erection Crane 1& '& )& *& +& 6& Percent of #(uipment eig5t Amount of #(iupment eig5t eig5t of 2eadac5e -all eig5t of -loc? eig5t of Lifting -ar eig5t of Slings and S5ac?les Total eig5t < Lbs& Lbs& Lbs& Lbs& Lbs& 7& 8& 9& 1:& 11& Lbs& Tai in$ Crane 1& '& )& *& +& 6& Percent of #(uipment eig5t Amount of #(iupment eig5t eig5t of 2eadac5e -all eig5t of -loc? eig5t of Lifting -ar eig5t of Slings and S5ac?les Total eig5t < Lbs& Lbs& Lbs& Lbs& Lbs& 7& 8& 9& 1:& 11& Lbs& eig5t of >ib #rected Stored eig5t of >ib 2eadac5e -all eig5t of !able /Load ,all0 Au@iliar$ -oom 2ead "t5er: AAAAAAAAAAAAAAAAAA Lbs& Lbs& Lbs& Lbs& Lbs& Lbs& eig5t of >ib #rected Stored eig5t of >ib 2eadac5e -all eig5t of !able /Load ,all0 Au@iliar$ -oom 2ead "t5er: AAAAAAAAAAAAAAAAAA Lbs& Lbs& Lbs& Lbs& Lbs& Lbs&

Source of Load

eig5t:

(Name Plate, Drawings, Calculated, Weighed)

eig5ts Berified -$:

Page ) of +

Wieland-Davco Health and Safety Program January 2007

C.

Capacitie! of t(e Crane Erection Crane Confi$%ration

1& '& )&

T$pe of !rane %ated !apacit$ Lifting Arrangement a& Ma@& %adius During Lift b& Lengt5 of -oom c& Angle of -oom at Pic? d& Angle of -oom at Set e& %ated !apacit$ =nder Most Severe !onditions 1& "ver %ear '& "ver ,ront )& "ver Side f& %ated !apacit$ for Lift >ib a& b& c& d& Is t5e >ib to be used3 Lengt5 of >ib >ib Angle %ated >ib !apacit$ Tons ,t& ,t& Degree Degree Lbs& Lbs& Lbs& Lbs& 1es;No ,t& Deg& Lbs

*&

+&

!able a& Number of Parts b& SiCe of !able c& Ma@imum !apacit$ Percent of Crane! Capacit, Total eig5t @ 1:: %ated !apacit$ D

Inc5& Lbs

D.

<

E.

#i-e of # in$! 1& Sling Selection a& T$pe of Arrangement b& Number of Slings to 2oo? c& Sling SiCe d& Sling Lengt5 e& %ated !apacit$

Inc5& ,t& Lbs&

Page * of +

Wieland-Davco Health and Safety Program January 2007

C.

Capacitie! of t(e Crane Tai in$ Crane Confi$%ration

1& '& )&

T$pe of !rane %ated !apacit$ Lifting Arrangement a& Ma@& %adius During Lift b& Lengt5 of -oom c& Angle of -oom at Pic? d& Angle of -oom at Set e& %ated !apacit$ =nder Most Severe !onditions 1& "ver %ear '& "ver ,ront )& "ver Side f& %ated !apacit$ for Lift >ib a& b& c& d& Is t5e >ib to be used3 Lengt5 of >ib >ib Angle %ated >ib !apacit$ Tons ,t& ,t& Degree Degree Lbs& Lbs& Lbs& Lbs& 1es;No ,t& Deg& Lbs

*&

+&

!able a& Number of Parts b& SiCe of !able c& Ma@imum !apacit$ Percent of Crane! Capacit, Total eig5t @ 1:: %ated !apacit$ D

Inc5& Lbs

D.

<

E.

#i-e of # in$! 1& Sling Selection a& T$pe of Arrangement b& Number of Slings to 2oo? c& Sling SiCe d& Sling Lengt5 e& %ated !apacit$

Inc5& ,t& Lbs&

Page + of +