Certification No.: LCWork Permit No.: PTW-MA1-
LIFTING CERTIFICATE
SECTION 1 – REQUISITION
Date:
Time:
APPLICANT’S NAME…………………………………
COMPANY…………………….………………………
CARD NO./ ID NO…………………………………. ....
LOCATION/FACILITY…………………………………
WORK DESCRIPTION…………………………………………………….…………………………………………..
…………………………………………………………………………………………………………………………………………
SECTION 2 – TYPE OF LIFT
Major Lift (Above 80% of load chart)
Heavy Lift (10tons or more)
Lifts Below 10tons
SECTION 3 – CRANE INFORMATION
Truck mounted / Crawler Crane
TYPE OF CRANE
BRAND NAME
MODEL
SECTION 5 – ACTIVITY DETAILS
LOCATION OF LIFT
LENGTH OF BOOM
RADIUS
RIGGING WEIGHT
BLOCK
kg JIB
kg
SLINGS/SHACKLES
kg BALL
kg
SPREADER BAR
kg LOAD LINE
kg
UPPER BOOM PT
kg PIN EXTRACTORS
kg
TOTAL RIGGING WEIGHT
CHART CAPACITY AT RADIUS
kg
WEIGHT OF OBJECT TO BE LIFTED
kg
TOTAL WEIGHT (PLUS RIGGING WEIGHT
kg
SAFETY FACTOR OF CRANE
kg
PERCENTAGE OF SAFETY CHART
kg
NUMBER OF PARTS PER LINE
each
RATED CAPACITY PER PART OF LINE
kg
ACTUAL LOAD PER PART LINE
kg
SECTION 4 – APPROVAL
CRANE SUPERVISOR
LIFT SUPERVISOR
APPROVING AUTHORITY
Name………………………………
Signature……………………………
Date……………..
Name………………………………
Signature……………………………
Date……………..
Name………………………………
Signature…………………………
Date……………..
Copy No. 1 – to be kept at site
Copy No. 2– Permit Office
Doc Code: MN1-AA-HS-PRO-OOO(G)-00001CL-12