MM/CRANE/01

PERMOHONAN PEMAKAIAN MOBILE CRANE / REQUEST FORM OF MOBILE CRANE OPERATION

1 PROYEK / Project DEMOLITION IFC 1
2 NO. WORK PERMIT / No. Permit To Work 02/LIFTING
3 HARI & TGL / Day & Date 18-Mar-19
4 ITEM PEKERJAAN / Work Item Remove Genset Caterpilar 2000KVA = 13,5T
5 PERMIT DIAJUKAN OLEH / Requested by
5.1. NAMA / Name Feri Fardian
5.2. JABATAN / Title Safety Adv
5.3. NO. HP / Celullar Number 085213759345
5.4. PERUSAHAAN / Company CV Margo Mulyo

6 JENIS CRANE YANG DIGUNAKAN / Type of Crane

6.1. MERK / Brand Tadano SILO valid sampai Tgl. / The Certificate valid until ###
6.2. KAPASITAS / Capacity 50 TON
6.3. KONDISI SAFETY DEVICE / Safety Device Condition v Berfungsi / Good Rusak / Broken
7 PERSON IN CHARGE
7.1. NAMA KI SUPERVISOR / Supervisor Name Jatiyoso (SM)
7.2. NAMA SAFETY STAFF / Safety Staff Name Sandi Santoso
7.3. NAMA OPERATOR & NO. SIO / Operator Name and License Number Maryasin / 89030-OPK3-MC/PAA/XI/2018
7.4. NAMA RIGGER / Name of Signalman Apip
7.5. JUMLAH PEKERJA / Number of Workers 6

8 JENIS MATERIAL YANG DIANGKAT / Type of Material Genset Caterpilar 2000 KVA = 13,5T
9 BERAT HOOK 500 Kg
10 RADIUS OPERASI / Operating Radius 6M
11 SUDUT ANGKAT / Boom Angle/ Degree 62 degree
11.1. BERAT TOTAL DIANGKAT (MATERIAL/CONCRETE, BAKET, ORANG) / Total of Weight (material/ concrete, bucket, person) 13,5T + 0,5T = 14T
11.2. SAFE WORK LOAD 23,5T x 80% = 18,8T > 14 T
11.3. KAPASITAS SLING ANGKAT WIRE SLING DIA. 26mm X 4 = 8T X 4 = 32 T > 16,5T
STATUS PENGANGKATAN / Status of Lifting v Aman / Safe Tidak Aman / Unsafe

12 SKET LOKASI KERJA, PENEMPATAN CRANE DAN RADIUS ANGKAT / Sketch of location, placement of Crane and mark of operating radius *)

12,1 LOKASI PARKIR / Parking Location Halaman Chiller Room

12,2 LOKASI TUJUAN / Destination Trailler

*) Penandaan lokasi kerja, crane dan radius dapat menggunakan tulisan tangan / Mark of location, crane &
operating radius can be used Handwriting

DIGESER DULU KELUAR MENGGUNAKAN

HYDROLIC JACKING

13 LAMPIRKAN LOAD CHART & BOOM ANGLE/ DEGREE CHART / Attach Load Chart & Degree Chart
PERSETUJUAN/ APPROVAL
Applicant
Nama/ Name Sandi Santoso
Jabatan/ Title Safety Officer
Tanda tangan/ Signature
Checked By Safety Staff
Nama/ Name Feri Fardian
OK / Not OK
Jabatan/ Title Safety Adv
Tanda tangan/ Signature
Approved By Client
Nama/ Name
OK / Not OK
Jabatan/ Title
Tanda tangan/ Signature
NOTE :
Boom Angle / Degree Chart

LOAD & BOOM ANGLE CHART

*) Form ini berikut lampirannya harus dipasang di lokasi kerja/ This form and the attachement should be displayed at location
*) Form ini harus di print dalam format kertas A3 / This form should be printed in A3 size