RICHLYNN CONTRACTING COMPANY, INC

LIFTING PLAN
Page 1 of 2 DATE:

1. PROJECT DATA CLIENT: JOB NUMBER: Main Crane Lifting Points: Lift Accomplishment Date:
WORK ORDER BY:

P.O./CONTRACT #

Main Boom

Jib Point

WORK PERFORMED:
2. CRANE DEFINITION Manufacturer: Model: Serial No.: Crane Description: Rated Capacity: Area of Operation: Crane Yearly Inspection Date: 4. CRANE CONFIGURATION Main Boom No. Sections: Boom Size: Boom Length: Boom Type: Hoisting From Main Boom: Main Boom Parts of Line: Main Boom Line Size (Dia) Capacity of line @ Parts Max. Load Radius Main Boom Max. Capacity of Lift Point Length of Main Boom Angle of Main Boom at Pick (Deg) Angle of Main Boom at Set (Deg) 5. LIFT WEIGHT DATA AND CALCULATIONS Weight of Load to be Lifted Max. Load Line Weight # Load Block Weight Qty: N/A # Rigging - Lifting Beams Qty: # Rigging - Slings Type: Nylon Capacity: # Rigging - Shackles Qty: # Type: 5/8" Anchor Shackle
Capacity:
#

National Crane 500C 28549 Boom Truck 15-Ton 180 Deg.Over Rear & Side

3. LOAD DATA A. Lift Description: 1. Equipment Number/Name: 2. Dimensions (L/W/H): 3. Total Gross Weight: 4. From Location to Location:
B. Maximum Operating Radius to be used During Lift (ft.):

N/A

Jib to be Used No. Sections: Jib Size: Jib Length: Jib Type: Jib Offset Angle: Jib Capacity of line @ Parts Jib Max. Load Radius Jib Max. Capacity of Lift Point Jib Length of Boom Jib Angle of Boom at Pick (Deg) Jib Angle of Boom at Set (Deg) Type of Ground Compact & Stable ( x )Yes ( ) No Surface Size: Structural Supports Required ( )Yes ( x )No 24" x 24" Other: Down Haul Weight Jib Stowed ( ) Yes ( X ) No Weight of Crane Components Total Weight of Lifted load & Crane Components Total Weight Plus Factor Of:
PERCENT CAPACITY THIS LIFT

( ) Yes

( X ) No

# # # # # # %

1.10

PRE-LIFT WORKSHEET
Note: To be fill out before a lift 6. LIFT ADMINISTRATION CHECKLIST Has pre-lift meeting been held with signal person/riggers/operator/site supervisor Operator assigned for the Lift (name) Print: Operator Certification Card Current (Must Be Current) Signal person designated (name) Print: Communication will be held by: Hand Radio Both or Other ( Please insert on Line) Has JHA been completed Has Swing Clearance Been Checked Has area been checked for safe entry and exit Tag lines are to be used: Description ( ) Diameter ( ) Length Location: Pre-Lift Huddle Conducted/Permit Secured Potential Hazards To Be Addressed: Weather: ( ) Yes ( ) No If yes please explain: ( ) Yes Sign: ( ) Yes Sign: ( ) Yes ( ) Yes ( ) Yes ( ) Yes ( ) No ( ) No Page 2 of 2

( ) No ( ) No ( ) No ( ) No

Electricity: ( ) Yes ( ) No

If yes please explain:

What is Wind Speed: Ground: ( ) Yes ( ) No

( ) 15mph consider shutting down lift If yes please explain:

( ) 20mph cancel lift

Surrounding Obstacles: ( ) Yes ( ) No

If yes please explain:

7. SIGNATURES OF PLAN DEVELOPERS & REVIEWERS Person responsible for lift: (operator) Print Site Supervisor: Print Client Representative: Print Other: Print Signature Date Signature Date Signature Date Signature Date

Critical Lifts: 1. Any lift, above 15 tons, over an operating unit, shelter or building 2. Any lift with a load greater than 50 tons 3. Any lift in which the combination of weight and lift radius will load the crane in the use above 80% of its rated capacity 4. Any lift requiring the use of more than one crane 5. Any lift in which a significant risk of personnel injury or equipment damage is possible