PDFWAC 296-155-56425
Sample declaration form for hours of experience.
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. WSR 12-01-086, § 296-155-56425, filed 12/20/11, effective 2/1/12.]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.