STATE OF NEW YORK
DEPARTMENT OF LABOR
DIVISION OF SAFETY AND HEALTH
SUBMIT
•
Signed (in ink) application
•
Check or money order for fee
due
•
Notarized GO-1, Appendix to
a License
CONTROL NO.
CERT NO.
EXPIRES
LICENSE AND CERTIFICATE UNIT
BUILDING 12, ROOM 161
STATE CAMPUS
ALBANY, NY 12240
(518) 457-2735
http://www.labor.state.ny.us
APPLICATION FOR CRANE OPERATOR'S CERTIFICATE OF COMPETENCE
1. SOCIAL SECURITY NUMBER
2. NYS DMV LICENSE OR ID NUMBER
3. LAST NAME OF APPLICANT
FIRST
MIDDLE I.
4. STREET AND NUMBER
6. DATE OF BIRTH
STATE
5. CITY, TOWN, VILLAGE
7. PHYSICAL CHARACTERISTICS
a. HEIGHT:
FT.
IN.
9. COUNTY
8. ZIP CODE
b. WEIGHT:
LBS.
10. TELEPHONE
HOME (
WORK (
)
c. HAIR COLOR
)
11a. Do you hold a valid crane operator's license issued by the Federal Government, another State or City?
YES
d. EYE COLOR
NO
11b. If you answered "Yes" give License and/or Certificate number and name and address of issuing agency
12a. Do you have a physical handicap or illness, such as epilepsy, heart disease, or an uncorrected defect in vision or hearing that might diminish your
ability to operate a crane?
YES
NO
12b. If you answered "Yes," please explain
I hereby make application for a Certificate of Competence as a crane operator and certify that the information on both sides of
this application is correct to the best of my knowledge. I authorize the DOL and the DMV to produce an ID card bearing my
DMV photo. I understand that DOL will send this card to the address I maintain with DOL. I also understand that DOL and DMV
will use my photo to manufacture all my subsequent ID cards for as long as I maintain my license/certification with the DOL.
13. Date
14. Signature
FOR OFFICE USE ONLY
APPROVED
Date
BY
A. Cable
B. Hydraulic
C. Boom Truck
D. Restricted Boom Truck
F. Line Truck
(Electrical Applications Only)
Signature
SH 830 (12-03)
NOTE: COMPLETE WORK EXPERIENCE ON REVERSE OF THIS APPLICATION
15. WORK EXPERIENCE Experience claimed will be verified.
CRANE EMPLOYER'S NAME
AND
MAILING ADDRESS
(INCLUDE APPRENTICESHIP TRAINING)
EMPLOYED IN THE OPERATION
AND
MAINTENANCE OF A CRANE
FROM
MO.
YR.
TO
MO.
YR.
CRANE TYPES OPERATED*
DUTIES
*Indicate the average percentage of time worked for each type of
crane that you operated
AVERAGE
HOURS PER WEEK
NUMBER OF (AVERAGE) WORKED
CABLE
HYDRAULIC
RESTR. LINE TRUCK
WEEKS
(LATTICE BOOM (CHERRY BOOM BOOM
(DIGGER
WORKED PER
CONVENTIONAL PICKER)
TRUCK TRUCK DERRICK)
YEAR
OPERATE MAINT. FRICTION)
(SIGN
HANGER)
16. Training Program(s) Attended; explain: Crane Schools; Management Courses; Military; Other:
17. Select the one CRANE TYPE which you would prefer to be tested on.
Cable a.k.a. Lattice Boom, Friction, Conventional
Hydraulic a.k.a. Cherry Picker (telescopic boom, swinging cab type, no max. mfg. rating)
Boom Truck (telescopic boom, truck mounted, operator stands, 28 tons mfg. rating capacity)
Restricted Boom Truck a.k.a. Sign Hanger (max. 3 ton mfg. rated capacity, up to 125 feet of boom)
Line Truck a.k.a. Digger Derrick (electrical applications only, nonconductive tip and nylon
rope, maximum 15 ton mfg. rated capacity, 65 foot maximum boom length)
18. Request for Written Test Center. Enter 1 after the city for your first choice of testing location. Enter 2 after the city for your second choice.
Please note that your choice is not guaranteed. The department may assign at its discretion.
Albany
Binghamton
Buffalo
Fredonia
Hicksville
Hornell
Kingston
Middletown
New York City
Nyack
Port Jefferson
Station
Poughkeepsie
Rochester
Saranac Lake
Syracuse
Utica
NEW YORK STATE
DEPARTMENT OF LABOR
APPENDIX TO A LICENSE APPLICATION
DIRECTIONS: [The child support obligations (New York State General Obligations Law) does not apply to corporations.]
1. Complete the CERTIFICATION section of this form if you are applying for a license or license renewal. The form
must be notarized.
2. Complete the RECERTIFICATION section of this form if you have previously submitted an Appendix to a License
Application, had child support obligations that were not being met, and are now applying for a renewal of your
license. The form must be notarized.
APPLICANT
a. Name
b. Social security number
c. Telephone number
d. List the type of business license being requested
e. Title
f. Business name (if applicable)
CERTIFICATION
ARE YOU UNDER AN OBLIGATION TO PAY CHILD SUPPORT?
YES
NO
If yes, complete items 1 > 4.
1. I am four months or more in arrears in the payment of child support .
TRUE
FALSE
2. I am making payments by income execution or by court agreed payment or
repayment plan or by plan agreed to by the parties.
TRUE
FALSE
3. My child support obligation is the subject of a pending court proceeding.
TRUE
FALSE
4. I am receiving public assistance or supplemental security income.
TRUE
FALSE
RECERTIFICATION
As required by Section 3>503.3 of the General Obligations Law, I am submitting the following RECERTIFICATION:
I am no longer in arrears in the payment of child support.
TRUE
FALSE
I am making payments by income execution or by court agreed payment or
repayment plan or by plan agreed to by the parties or repayment plan with the
appropriate support collection unit.
TRUE
FALSE
My child support obligation is the subject of a pending court proceeding.
TRUE
FALSE
I am receiving public assistance or supplemental security income.
TRUE
FALSE
I CERTIFY THAT AS OF THE DATE MY LICENSE APPLICATION IS FILED I AM UNDER NO OBLIGATION TO PAY
CHILD SUPPORT OR THAT I MEET AT LEAST ONE OF THE REQUIREMENTS LISTED ABOVE.
SWORN TO BEFORE ME THIS
,
DAY OF
SIGNATURE
TITLE (If any)
(NOTARY PUBLIC)
PLEASE REVIEW THE INFORMATION PROVIDED ON THE REVERSE
GO 1 (6>98)
CHILD SUPPORT OBLIGATIONS
Section 3 > 503 of the New York State General Obligations Law requires the following:
"2. Every applicant for a license or renewal thereof shall certify in the application in a written statement
under oath, duly sworn and subscribed, that as of the date the application is filed he or she is (or is not) under
an obligation to pay child support and that if he or she is under such an obligation, that he or she does (or
does not) meet one of the following requirements..."
A "LICENSE" means any certificate, license, permit or grant of permission required by the laws of this state,
its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation,
employment, trade, vocation, business, or profession, and shall also include any registration required by law
or agency regulation as a condition for such lawful practice.
PERSONS WHO ARE FOUR MONTHS OR MORE IN ARREARS IN CHILD SUPPORT OR WHO
HAVE FAILED TO COMPLY WITH A SUMMONS, SUBPOENA OR WARRANT RELATING TO A
PATERNITY OR CHILD SUPPORT PROCEEDING MAY BE SUBJECT TO SUSPENSION OF
THEIR BUSINESS, PROFESSIONAL AND/OR DRIVER'S LICENSES.
Section 3>503.3 states that an applicant who has child support obligations and who meets one of the requirements in
items 1 > 4 may have their license, permit, registration, certificate, approval, etc., issued or renewed.
"...but such license shall expire in six months unless before that time the applicant submits a written
certification under oath, duly sworn and subscribed that he or she:
a.
is no longer in arrears in the payment of child support ; or
b.
is making payments by income execution or by court agreed payment or repayment plan or by
plan agreed to by the parties or repayment plan with the appropriate support collection unit; or
c.
the child support obligation is the subject of a pending court proceeding; or
d.
he or she is receiving public assistance or supplemental security income.
Upon the submission of such certification, the expiration date of such license shall be governed by the agency's
customary practice and no fee, in addition to the initial license application fee, shall be charged unless the six month
period has expired.
Section 3>503.5, states in part,
"... THAT THE INTENTIONAL SUBMISSION OF FALSE WRITTEN STATEMENTS FOR THE PURPOSE OF
FRUSTRATING OR DEFEATING THE LAWFUL ENFORCEMENT OF SUPPORT OBLIGATIONS IS PUNISHABLE
PURSUANT TO SECTION 175.35 OF THE PENAL LAW."
STATE OF NEW YORK
DEPARTMENT OF LABOR
DIVISION OF SAFETY AND HEALTH
LICENSE AND CERTIFICATE UNIT
BUILDING 12, ROOM 161, STATE CAMPUS
ALBANY, NY 12240
(518) 457>2735
CRANE OPERATORπS CERTIFICATE OF COMPETENCE
INFORMATION AND INSTRUCTIONS FOR APPLICANTS
Section 482 of the General Business Law provides that an individual or owner who operates a crane on a construction,
demolition or excavation site outside New York City must obtain a certificate of competence issued by the Commissioner of Labor.
REQUIREMENTS
AGE
Applicant must be at least 21 years old.
EXPERIENCE
Applicant must have at least three years of practical experience in the operation of a crane
having a manufacturerπs maximum rated capacity exceeding 5 tons or 40 foot of boom, and
of the following type: a crane which consists of a mobile carrier mounted, power operated
hoisting machine utilizing hoisting rope and a power operated boom movable laterally by
rotation of the machine on the carrier. In addition, applicant must have practical
knowledge of crane maintenance.
PHYSICAL CONDITION
An applicant will not be certified by the commissioner if suffering from an uncontrolled
physical handicap or illness, such as epilepsy, heart disease, or from an uncorrected defect
in vision or hearing, which might diminish competence.
GENERAL EXAMINATION
Each applicant for a certificate of competence will, and each applicant for a renewal of
such certificate may, be required by the commissioner to take an appropriate general
examination. It will include questions to test mechanical aptitude as well as knowledge of
internal combustion engines, hydraulic controls and systems transmissions, clutches, brakes
hoisting drums, wire rope, the OSHA construction crane standard and the provisions of
Code Rule 23 pertaining to the safe operation of cranes.
PRACTICAL EXAMINATION
An applicant who passes the general examination will be required to take a practical
examination in crane operation, except that the commissioner may waive this requirement
with respect to renewal applicants.
Note:
The fee submitted with an original application will permit an applicant to take the
general examination and the practical examination the next two times each
examination is given. Failure to appear at a test will be considered a failure.
If an applicant fails to appear or fails to pass either examination after the second
time, a new fee must be submitted before the applicant will be scheduled for
another test appointment.
EXCEPTIONS
A certificate of competence is NOT required if the operator is:
(1) at least 21 years old and is employed by the federal government, the State, or a
political subdivision, agency or authority of the State and is operating a crane owned
or leased by such agencies and the assigned duties include operation of a crane;
(2) at least 21 years old and is employed only to test or repair a crane and is operating it
for such purpose while under the direct supervision of a certified crane operator;
(3) an apprentice or learner at least 18 years old and has the permission of the owner or
lessee of a crane to take instructions in its operation and is operating such crane under
the direct supervision of a certified crane operator.
SH 831 (6>03)
HOW TO APPLY
FORMS
Obtain an application packet from the New York State Department of Labor, Division of
Safety and Health, License and Certificate Unit, Building 12, Room 161, State Campus,
Albany, NY 12240. Submit the completed application or any specific questions on the
Crane Operatorπs Certificate to the License and Certificate Unit.
Complete the ™Application for Crane Operatorπs Certificate of Competence∫, in duplicate.
VERIFICATION
Work experience will be verified with your employer. If self>employed, send proof of crane
equipment ownership. This may include invoices, cancelled checks, 1099s, attestation of
crane equipment ownership on company stationary, or other appropriate documentation.
At least one (1) letter of reference from another company, on company letterhead should
be provided. This letter of reference should verify your crane experience, including the
type of crane(s) operated and time spent in crane operation.
CHILD SUPPORT OBLIGATIONS
Every applicant applying for or renewing a certificate or license must complete a notarized
statement swearing that he or she is (or is not) obligated to pay child support, and that if
he or she is under such obligation, he or she does (or does not) meet the requirements
listed on the GO 1, Appendix to a License Application.
PHOTOGRAPHS
The New York State Department of Labor (DOL) has entered into an agreement with the
New York State, Department of Motor Vehicles (DMV) to produce the photo ID certificates
formerly generated by the DOL. All applicants for new and renewed certifications and
licenses, that currently contain a photograph, will have to have a current New York State
photo License or Non>Driver ID card. Anyone without a New York State photo Drivers
License may have their photo taken at any nearby NYS DMV office. Check with the NYS
DMV for acceptable proofs of identity before going to the DMV for photos; they have
stringent requirements. Telephone or check their website at www.nysdmv.com.
FEE
Prepare a check or money order for §60.00 made payable to the Commissioner of Labor;
the fee is non>refundable.
SUBMIT
Forward one completed application, the Appendix to a License Application, and the fee;
keep one completed application for your records.
GENERAL INFORMATION
EXAMINATION
Approximately two weeks before examinations are held, the License and Certificate Unit
will notify you regarding the dates, times and locations of the general and practical
examinations.
IF AN APPLICANT FAILS TO APPEAR OR FAILS TO PASS EITHER EXAMINATION AFTER THE
SECOND TIME, ANOTHER §60.00 FEE MUST BE SUBMITTED BEFORE THE APPLICANT WILL
BE SCHEDULED FOR A NEW TEST.
TERM OF CERTIFICATE
The certificate is valid for three years from the date of issuance.
CARRYING CERTIFICATE
The certificate must be carried at all times when operating a crane. Failure to produce such
certificate upon request will be presumptive evidence that the operator is not certified.
CHANGE OF ADDRESS
The License and Certificate Unit must be notified of any change in your address. Failure to
send in this information may prevent delivery of your certificate or your renewal
application.
RENEWAL
Renewal applications will be mailed to each holder of a certificate of competence 30 days
prior to the expiration date.
DENIAL OF CERTIFICATE
Any applicant whose application for a Crane Operator's Certificate of Competence has
been denied may request a hearing before the examining board. A request (in writing)
must be submitted to the Commissioner of Labor within 30 days after the mailing or
personal delivery of the Notice of Denial.
New York State Department of Motor Vehicles
REQUEST FOR PHOTO ID CARD
If you don’t already have a NYS Driver License or Non-Driver ID
Your new photo identification card from the Department of Labor will be provided by the NYS Department of
Motor Vehicles (DMV). To do this, DMV must take your picture.
Ø
If you already have a valid NYS Driver License or Non-Driver ID Card with a photo, please refer to your
Department of Labor application for instructions.
Ø
If you do not have a valid NYS Driver License or Non-Driver ID Card with a photo, you must visit a DMV
office to have your picture taken. Bring this form and proof of your name, date of birth, and signature to the
DMV office (see “Identification Requirements” below). After reviewing your proofs, a DMV staff member
will take your picture and give you a receipt. Your receipt will have a 9-digit ID number assigned by DMV.
Write that number on your Department of Labor application.
If you want, you can apply for a NYS Non-Driver ID Card when you have your picture taken at the DMV office.
IDENTIFICATION REQUIREMENTS
Before DMV can take your photo, you must provide proof of name, and proof of date or birth. All proofs must be
original documents or documents certified by the agency that issued them. At least one proof must show your
signature. Photocopies are not acceptable. Documents of the same type count as only one proof (for example, two
or more credit cards count as only one credit card). For a list of acceptable documents for proof of identity and proof
of date of birth, see DMV form ID-44.
Warning – DMV will not accept documents with alternations or erasures. Any such documents may be confiscated.
Presenting fraudulent documents may also result in criminal prosecution.
DMV OFFICE INSTRUCTIONS:
Name
Date of Birth
SEX
The NYS Department of Labor referred this customer to DMV for an Image Capture Only (ICO) transaction.
(Reminder: The ICO is a no-fee transaction.) If the customer only needs an ICO for the Department of Labor’s
ID card, an MV-44 application is not needed. However, if the customer also wants to obtain a Non-Driver ID
Card, have him/her complete an MV-44, and process as usual.
In either case, review the customer’s proofs of name, date of birth and signature for acceptability. Identify the
proofs the customer provides by checking them on an ID-44. Print the customer’s name, date of birth, and sex
in the spaces above. Staple the office copy of the FS-6T to this page and to the ID-44 (and to the MV-44 if one
is needed), and place the pages in your batch paperwork. Tell the customer to keep his/her copy of the FS-6T,
because he/she will need the client ID# that is printed on the FS-6T.
ID-5 DOL (3/03)