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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:
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 (LBC)
300 tons and above
Hours
300 tons and above
Hours
 
 
 
Under 300 tons
Hours
Under 300 tons
Hours
 
(b)
Lattice Boom Truck Cranes (LBT)
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) (TLL) (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) (TSS) (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)
Luffer
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; and/or has direct control of that crane; and/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 jumping (increasing 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 inspector, 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, 2011.
 
 
 
 
 
 
 
 
Signature of Operator
 
[Statutory Authority: RCW 49.17.010, 49.17.040, 49.17.050, 49.17.440, 49.17.060, and 29 C.F.R. 1926, Subpart CC. WSR 12-01-086, § 296-155-56425, filed 12/20/11, effective 2/1/12.]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.
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