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Organization Name: HAMTE Work Permit Required? YES NO

Facility Name: Steel Erection Specific Work Location: Date of Lift:

A) Load Description & Weight (From USER): B) Load Handling Devices (See “Notes” Below):
Tons Load Handling/Boom Stowed Erected N/A Weight:
Attachments Tons
C) Crane Information (See “Notes” Below): Swing-Away Jib: □ □ □
1. Inspection Sticker YES NO Other Jibs: □ □ □
2. Inspection Sticker Expiry Date: Hook Block (Main):
3. Equipment ID #: Auxiliary Boom Head:
4. Crane Model: Headache Ball:
5. Crane Type: Lifting/Spreader Beam Needed? YES NO

6. Crane Rated Capacity: Tons Does Beam Have Current Inspection Sticker? YES NO
Slings, Shackles, etc.:
7. Crane Operating Code # (if applicable):
Other:
8. Single Line Pull Capacity: Tons
9. # of Parts of Line: Weight of Load Handling Devices (Section B Above) Tons
+ Weight of Load to be Lifted (Section A) Tons
10. Total Gross Capacity Hook Block as Reeved:
Tons Tons
= Total Gross Weight (Sections A + B)
D) Crane Configuration (See “Notes” Below): E) Rigging (See “Notes” Below):
1. Required Boom Length: ft/m 1. Hitch Arrangement:
2. Boom Angle: degrees 2. Sling Type(s):

3. Required Counterweight: Tons 3. Sling Size(s): in/cm

4. Sling Length(s): m
4. Operating Radius: m 5. Shackle Size: in/cm & Capacity: Tons
5. Lift Quadrant (Front, Rear, 360°): 6. Capacity of Above Configuration: Tons
F) Crane Capacity In This Configuration (Derated, if applicable): Tons Total Gross Weight ÷ Capacity = %
G) Surface Requirements Needed (Other Than Mandatory Outrigger Pads): Mats? YES NO Is the Ground Level? YES NO
Proper Ground Compaction? YES NO Excavation Hazards Controlled? YES NO Other ? YES NO
H) Wind Speed Shall Not Exceed Limits for Man baskets or Lifting Operation Limits/Manufacture's Specifications for Loads
I) Energized Power-Lines Within Boom Radius? YES NO Explosion/Fire/High Heat Hazards Within Boom Radius? YES NO
J) Is This a Nighttime Crane Lift? YES NO If Yes, Do You Have Written Approval From Facility Manager? YES NO
*Attention: A Pre-Lift Safety Meeting is Mandatory CAN CRANE MAKE LIFT? YES NO
Positions: Name (Signature) Badge # Certificate # Approved by: Rigger-I/Rigging Competent Person
Rigger:
Name:
Crane Operator:
Certificate #:
Supervisor:
Signature:
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Critical Lifting Plan

Notes: 1. Attach sketch (es) of lift site, noting obstacles to movement of load, boom, or tail swing.
2. All units of weight shall be listed in the same units of measure as Crane Load Chart.
3. All units of measure shall be listed in the same units of measure as Crane Range Diagram.
4. Attach copy of Crane Load Chart, Range Diagram, and Safety Notes.
5. Certain weights may be deducted from Crane Load Chart capacities based on manufacturer’s specifications.