WAC 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: 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 300 tons and above Hours 300 tons and above Hours Under 300 tons Hours Under 300 tons Hours (b) Lattice Boom Truck Cranes 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) (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) (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) Luffing boom 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; or has direct control of that crane; 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 climbing (increasing or decreasing 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 certifier, 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, 20. Signature of Operator 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 300 tons and above Hours 300 tons and above Hours Under 300 tons Hours Under 300 tons Hours (b) Lattice Boom Truck Cranes 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) (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) (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) Luffing boom 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; or has direct control of that crane; 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 climbing (increasing or decreasing 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 certifier, 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, 20. Signature of Operator