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About Us
Leadership
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Development
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Development Projects
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For Sale/Lease
Subcontractors
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Safety
Crane Lift Plan Form
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Crane Lift Plan Form
Email to
Lift Plan Responsible Person
Project Name
Date of Lift
MM slash DD slash YYYY
Lift Location
Subcontractor’s Name
Contact Name
Contact Number
Rigger ID
Signal Person ID
This field is hidden when viewing the form
Crane Company’s Name
Contact Name
Contact Number
Operator ID
A/D Supervisor ID
Crane Information
Make
Model
S/N
Capacity (tons)
Date Manufactured
MM slash DD slash YYYY
Does lift involve (if any box is checked, lift is critical)?
≥75% chart capacity
Two hooks
Over public space
Dual crane
Traveling with Load
Tripping load
Personnel basket
Other
if Other
Carrier Information
Truck
Rough Terrain
All Terrain
Crawler Block
Other
Boom Information
Boom Information
Telescoping
Lattice
Block capacity (tons)
# of Parts Line
Line Pull (lbs)
Working Boom Length (ft)
Jib Information
Jib deployed?
No
Yes - is it
Fixed
Luffing
Block capacity (tons)
Offset
# of Parts Line
Boom and Jib - Combined Length (ft)
Line Pull (lbs)
Jib length (ft)
Power Line Encroachment Over Herd Review
Max working radius (ft)
plus ½ length of load (ft)
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Will max working radius (plus ½ length of load) be within 20’ of an overhead power line?
No
Yes
If yes, provide power line voltage
If yes, provide power line safety JHA - see OSHA subpart CC
FAA Permit Review
Max working boom tip elevation (as assembled) in ft
Will max vertical boom elevation exceed 200’ above existing site elevation?
No
Yes
If yes, provide FAA permit no.
Outrigger Configuration / Distributed Load
Outrigger Configuration / Distributed Load
Fully Extended
Fully Retracted
Intermediate
Rubber (PSI)?
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Crane cribbing dimensions?
Distributed Ground Bearing Pressure (PSF)?
Crane Condition
Was crane idle >3 months since annual inspection?
No
Yes
Date of Annual
MM slash DD slash YYYY
s crane a lattice boom?
No
Yes
Note regarding 3rd party inspection: If crane has been idle for longer than 3 months since last 3rd party annual inspection (inspection), or if crane being A/D is a lattice boom a new inspection certification and report must be provided post A/D). Exception: hydraulic crane with stowed jib that was included in the current annual 3rd party inspection. Inspector must be certified with CCAA (www.CCAAweb.net).
Itemization of Crane Chart and Load Calculation
Weight of Heaviest Load (lbs)
Comment
Rigging (lbs)
Comment
Jib (lbs)
Comment
Jib Hook (lbs)
Comment
Hook Block (lbs)
Comment
Load Line (lbs)
Comment
Other (lbs)
Comment
Gross Load below Tip(lbs)
Comment
Lift Summary
Max Working Radius
Boom Angle
Gross Load
Chart Capacity
% of Capacity
(Gross Deductions / Chart Capacity)
Load Characteristics
Will this crane lift plan cover multiple picks?
No
Yes
Explain
Dimensions of load(s) creating highest % of capacity (height x width x length)
Description of load(s) creating highest % of capacity (i.e. worst case load)
Other dimensions, as follows
Weight of load creating highest % of capacity (lbs)?
Calculation provided with rigging diagram
Manufacturer product data sheet provided
How will the Center of Gravity (COG) of the load be determined?
Manufacturer data sheet – see attached
Calculation – see attached
In Field – explain below
Upload Manufacturer data sheet
Max. file size: 2 GB.
Upload Calculation
Max. file size: 2 GB.
In Field – explain
Will any load be upended?
No
Yes
If yes, provide stability evaluation from manufacturer or PE
Rigging Information
List rigging components - be specific: manufacturer, number of pieces, description, size, length, capacity and component weight (NOTE: Job built equipment must be engineered and proof tested per OSHA 29 CFR 1926.251(a)(4)).
Identify the minimum capacity component
Capacity (lbs)?
Rigging diagram
Max. file size: 2 GB.
Crane Location/Clearances
Provide a to-scale plot plan showing crane location, adjacent buildings, pipe racks, and other significant obstructions within load swing radius. Indicate direction and span of swing
Max. file size: 2 GB.
Upload Load Charts
Drop files here or
Select files
Max. file size: 2 GB.
Provide a to-scale elevation plan depicting crane, adjacent structures, and load
Max. file size: 2 GB.
What is the horizontal distance from the crane center pin to the nearest structure?(ft)
What is the minimum clearance from boom to highest point of structure during a pick?(ft)
What is the minimum clearance tip to surround my structure during a pick?(ft)
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What is the minimum distance from boom to load during a pick?(ft)
Has site been reviewed (actual and documentary information) as part of the development of this crane lift?
Yes (and, no further information required)
Yes (and, the following add’l information requested)
Information
Will the crane setup (or load) area be within zone of influence of foundation or underground facility?
No
Yes
explain what additional measures will be taken to establish proper support for crane
Describe signaling method
Hand
Voice
Voice with hands free radio for operator
Other
Explain
Non-compliance with any part of this Crane Lift Plan will be grounds for immediate cessation of work and possible permanent removal from the site
Crane Company Responsible Person Signature
Subcontractor Responsible Person Signature
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