DDEESSIIGGNN--BBUUIILLDD PPRROOCCEEDDUURREESS MMAANNUUAALL · the Design-Builder’s schedule, or...

DDEESSIIGGNN--BBUUIILLDD

PPRROOCCEEDDUURREESS MMAANNUUAALL

SEPTEMBER 2005

VVOOLLUUMMEE VV OOFF VV

EEXXHHIIBBIITT VV –– FFOORRMMSS FFOORR DDEEPPAARRTTMMEENNTT UUSSEE

(Project Name)

DESIGN-BUILD PROJECT

PIN _____________

EXHIBIT V

FORMS FOR DEPARTMENT USE

This page is intentionally left blank.

New York State Department of Transportation

_________ Project Exhibit V – Forms PIN ____________ [Insert date]

EXHIBIT V – LIST OF DEPARTMENT USE FORMS

Analysis Record for Partial Payments - Allowances and Reductions BR 342 – Concrete Materials Certification Construction Progress Schedule Contract Information D/M/WBE Subcontractor’s Item(s) of Work Decrease in Scope of Work Estimate Need Sheet Estimated State Staff Overtime Hours Final Certification Form Final Contract Payment Letter Final Inspection for Bonded Items GE352b (DB) – Project Inspection Report Bituminous Stabilized Course HC 193a (DB) – Sample and Testing of Materials Certification R45c (DB) – Notice of Final Inspection / Recommendation of Contract Acceptance HC199 – Request for Reestablishment of Approaches to Private Lands HC90 – Permission to Re-Grade and Re-Sod or Seed Lawn HC90a – Permission to Replace Sidewalks HC91b – Permission to Plant Trees and Shrubs Health and Safety Plan Increases in Scope of Work List of Utility Poles MPT Request - Maintenance & Protection of Traffic Request Murk 2b-DB-CCE – Construction Compliance Engineer’s Daily Project Diary Murk 2b-DB-DCE – Design Compliance Engineer’s Daily Project Diary Murk 4d-DB(1) – Department’s Asphalt Concrete Daily Field Inspection Report New Construction Project Information Order to Stop Work Order-on-Contract Transmittal Permission to Access Release for Private Property Price Center - Interim Payment Project Emergency Contact Persons R.O.W. Monumentation Recommendation for Final Acceptance of Project Release of Uncompleted Work Agreement Report of Design-Builder’s Initial Entry upon New Row Parcels Request to Proceed at Risk Route Travel Restriction Status of Bridge under Construction Status of Subcontractors Subcontractor Evaluation Traffic Signal Equipment Summary Transmittal Form Utility Meeting Minutes Value Engineering Change Proposal Summary Wage Rate Interview Waiver of Material Safety Data Sheet (MSDS) Requirement 619-5 – Basis of Payment

New York State Department of Transportation ANALYSIS RECORD FOR PARTIAL PAYMENTS ALLOWANCES AND REDUCTIONS Comptroller's Contract No. ______ Region ______

Analysis Record Form

(JOB STAMP)

Item Spec. No.

Auth. Contract Qty.

Unit Price

Invoice Numbers

NOTE: ATTACH INVOICES & IDENTIFY ITEM SPECIFICATION NO.

THEREON, IF MATERIAL IS STORED ON PRIVATE PROPERTY, A LIEN RELEASE & STATEMENT OF INGRESS, EGRESS & REGRESS ARE REQUIRED.

This analysis record pertains to partial payment in fiscal share .

Est. No.

Est. No.

Est. No.

1. Contract Work Authorized

(Price Center Value)

2. Less Total Contract Work Done Including This Estimate

(Cumulative Amount Earned)

3. Balance Contract Work Remaining To Be Done

(line 1 - line 2)

4. Partial Payment Limit

(85% of line 3)

5. Less: Net Partial Payment Made to Date

(line 12 of prior transaction)

6. Balance: Max. Amount Eligible for Partial Payment

(line 4 - line 5)

7. Material Cost

(per attached invoices)

8. Partial Payment Allowed This Estimate

(lower of line 6 or 7)

9. Partial Payments Allowed to Date

(line 5 + line 8)

10. Withdrawal Rate

(qty. withdrawn ) qty. in inventory prior to withdrawal) X 100

%

%

%

11. Partial Payment Reduction This Estimate

(line 9 X line 10)

12. Net Partial Payments Made to Date

(line 9 - line 11)

____________________________________ DPM Signature & Date


BR 342

MATERIALS CERTIFICATION Portland Cement Concrete Asphalt Concrete SHIPPED FROM: PLANT: _____________________________________________ PLANT NO. ______________ LOCATION: __________________________________________ REGION ________________ __________________________________________ SHIPPING DATE: _________ SHIPPED TO: PROJECT NO. _________________________ LOCATION ____________________________ ____________________________ *Use Item Number when material is not designated by Class/Mix Type I certify that the material delivered with the delivery ticket to the above noted project was proportioned in accordance with the requirements of the Contract Specifications for the specific class/mix/item noted using New York State Department of Transportation approved materials. BY __________________________________________ TITLE _______________________________________ DATE: ____________________

Class/Mix Type * Quantity

JOB STAMP

STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION

ALBANY, N.Y. 12232 http://www.dot.state.ny.us

JOSEPH H. BOARDMAN GEORGE E. PATAKI COMMISSIONER GOVERNOR [ DATE ] [ DESIGN-BUILDER ] [ ADDRESS ] Re: [ D # ] [ PROJECT DESCRIPTION ] Dear ____________: This is in reference to the proposed construction progress schedule for Contract [ D # ], received in our office [ DATE ]. Based on review of the progress schedule, we have the following comments: The progress schedule is approved, provided the Design-Builder employs and supplies a sufficient force of workers, materials and equipment to maintain the progress indicated on the schedule. Approval of the Design-Builder’s schedule by the Department does not relieve the Design-Builder of any of its responsibility what so ever for the accuracy or feasibility of the Design-Builder’s schedule, or of the Design-Builder’s ability to meet the Contract completion date, nor does said approval expressly or impliedly warrant, acknowledge or admit the reasonableness or durations or logic of the Design-Builder’s schedule. Respectfully, Department’s Project Manager cc: [ NAME ], Asst. Regional Construction Engineer, Region [ # ] Project File


Contract Information

CONTRACT INFORMATION

FIRST DAY OF WORK______________ DPM:________________________________ HOME PHONE:__________________________ DESIGN-BUILDER_____________________SUPERINTENDENT:______________________ DESIGN-BUILDER’S FED. I.D. NUMBER:_________________________________________ DESIGN-BUILDER’S EMERGENCY NUMBERS: Name Phone # (Area Code) Cell Number FIELD OFFICE ADDRESS ________________________________________________ Street Apt/Rm #

________________________________________________ Town/City Zip Code

PLEASE NOTE THAT THE NYSDOT REGIONAL CONSTRUCTION OFFICE WILL BE USED AS YOUR MAILING ADDRESS UNLESS WE ARE OTHERWISE INSTRUCTED. FIELD OFFICE PHONE & FAX NUMBER:________________________(WITH AREA CODES) DESIGNATED M & P PERSON:___________________________________________ Description of how to get to the field office from intersection of two nearest State Highways:

(Map on back if necessary) One-way mileage to the Regional Office:___________ Prepared by:__________________________________

NOTE: COMPLETE AND SUBMIT TO THE REGIONAL OFFICE AS SOON AS POSSIBLE

Job Stamp


1 of 2

CONTRACT: D_________ DESIGN-BUILDER:____________________________________________ D/M/WBE SUBCONTRACTOR:___________________________________ REGION:________________ DATE:__________________ D/M/WBE SUBCONTRACTOR’S ITEM(S) OF WORK: Please attach:

A. A copy of the AAPHC89/AAPPHC89-1 to each questionnaire for applicable D/M/WBE subcontractors; and

B. A copy of all AAP19's.

1. Did the D/M/WBE begin item(s) of work on time and continue working on schedule so that no other contract work was delayed? Y N COMMENTS: 2. Did the D/M/WBE appear to be familiar with the contract

documents, i.e. plans, proposals, standard sheets, standard specifications, materials acceptances? Y N

If NO, did the D/M/WBE rely on the Design-builder or Department’s forces for this information? COMMENTS: 3. Did the D/M/WBE perform the work with:

A. Their own workforce Y N

B. Design-Builder’s workforce Y N

C. Combination of both Y N

If “B” OR “C”, please explain in detail.


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COMMENTS: 4. Name of the D/M/WBE’s supervisor/contact person, (the person you

spoke with when dealing with the D/M/WBE):___________________________________ 5. Was the equipment used by the D/M/WBE: (check all that apply)

A. Leased from the Prime and/or other subcontractor. Y N

B. Leased by the D/M/WBE Y N

C. Owned by the D/M/WBE Y N Was the equipment adequate and reliable? Y N COMMENTS: 6. Was effective communication between the D/M/WBE

and yourself maintained throughout the contract? COMMENTS: 7. Based upon your observation of work performed on GOOD _____

this project, how would you rate the D/M/WBE’s ADEQUATE _____ performance? POOR _____

COMMENTS: 8. Based upon your observation of the D/M/WBE’s performance,

would you recommend a specific type of assistance that would most benefit the D/M/WBE, (i.e. project scheduling, labor/equipment resource management, quality control)?

COMMENTS:


Decreases in Scope

D [# # # # # # ]

OOC # [ # ]

DECREASES IN SCOPE OF WORK PRICE CENTER NO. DESCRIPTION EXPLANATION/EXTENT OF

DECREASE


ESTIMATE NEED SHEET CONTRACT: D__________ FOR ESTIMATE # ____ ENDING __________________ Please submit to the Field Office ASAP the following documents for the release of the Estimate. No payment will be made for items in need of the below certification. Payroll: EEO: Material Certification: Misc: Prepared By: ______________________________ Date: ____________

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M E M O R A N D U M NEW YORK STATE DEPARTMENT OF TRANSPORTATION

TO: [RCE Name], Region [ # ], Construction Engineer Attention: [ Name ], Area Supervisor FROM: [ Your Name ], Department’s Project Manager SUBJECT: ESTIMATED STATE STAFF OVERTIME HOURS CONTRACT [ D# ] [ Project Description ] DATE: [ Date ]

ESTIMATED OT hrs. for this pay period # _______: NAME LINE # HRS. NAME LINE # HRS.

ACTUAL OT hrs. for this pay period # ______:

NAME LINE # HRS. NAME LINE # HRS.

ESTIMATED OT hrs. for next pay period # ______: NAME LINE # HRS. NAME LINE # HRS.

2 of 2

I realize this may be subject to change for conditions outlined by my Area Supervisor. Any revisions should be resubmitted for approval.

For Regional Construction Office Use

� Approved __________ (supervisor’s initials) � Disapproved ___________ (supervisor’s initials) (If disapproved, please explain on reverse) � Resubmitted & approved ___________ (supervisors’ initials) Date returned to EIC ___________

State Of New York Department of Transportation

FINAL CERTIFICATION FORM CONTRACT AWARD DATE: ____________________ ORIGINAL CONTRACT COMPLETION DATE: ____________________ FIRST DAY OF WORK: ____________________ LAST DAY OF WORK: ____________________ EXTENSIONS OF TIME GRANTED TO: ____________________ DATE OF REGIONAL DIRECTOR’S RECOMMENDATION OF ACCEPTANCE:_____________ DATE OF ACCEPTANCE BY THE CONSTRUCTION DIVISION: ____________________ ALL MATERIALS INCORPORATED IN THIS CONTRACT HAVE BEEN TESTED AND ACCEPTED AS SPECIFIED IN THE NEW YORK STATE DEPARTMENT OF TRANSPORTATION SPECIFICATIONS OF ___. ACCEPTANCES, CERTIFICATIONS, AND TEST NUMBERS HAVE BEEN RECORDED IN THE FINAL BOOKS. ________________________________________ - DEPARTMENT’S PROJECT MANAGER



JOSEPH H. BOARDMAN GEORGE E. PATAKI COMMISSIONER GOVERNOR [ DATE ] [ DESIGN-BUILDER NAME ] [ ADDRESS ] RE: [ D # ] [ PROJECT DESCRIPTION ] Dear [ DESIGN-BUILDER NAME ]: Attached for your review is a summary of final contract quantities for the subject contract. [Include only if there are unit priced items in the Contract.] In accordance with Section 109 of the Contract Documents, the final agreement for the project referenced herein will not be drawn and finalized “until all work required under the contract has been satisfactorily completed, all claims presented and all accounts for extra work and materials have been rendered, considered, and if agreed to, made a part of such final agreement”. Additionally, in accordance with Specification Section 109-13, certain documents and submissions are considered to be necessary to enable timely processing of the final payment. As of the date of this letter, the following have not yet been received and may delay the processing of the final payment:

[LIST ANY MISSING DOCUMENTATION. IF ALL DOCUMENTATION HAS BEEN SUBMITTED, MODIFY THIS LETTER ACCORDINGLY.]

As Design-Builder for the subject contract, you are hereby required to promptly submit to this office any exceptions or disputes relative to the proposed final contract payment, accounts for extra work and materials, together with supporting measurements and/or data, and any other documentation listed above. In order to be considered as a part of the final agreement, your reply with supporting documentation must be received by this office within fifteen (15) days of the date of this letter. If this deadline presents a serious problem, please notify this office by certified mail within fifteen (15) days of the date of this letter as to when you will forward the required information. If we do not receive any notification from you within fifteen (15) days of the letter, we will assume you are in agreement with the final contract payment and have no disputes. We will, therefore, proceed with the processing of the final estimate. Very truly yours, ________________________________ Your name Department’s Project Manager cc: [ RCE NAME ], Regional Construction Engineer, Region [ # ]

File

M E M O R A N D U M NEW YORK STATE DEPARTMENT OF TRANSPORTATION

TO: (RCE name), Regional Construction Engineer FROM: (DPM), D___________ DATE: (Current) SUBJECT: (Project Description) Final Inspection for Bonded Items

This memo is to inform you that I have made the 180-day performance inspection of (List all items with descriptions), on (date of inspection). All striping was within specifications tolerances and the performance bond can be released at this time.

cc: Project Files


GE352b (DB)

PROJECT INSPECTION REPORT BITUMINOUS STABILIZED COURSE

Date: _____________________

To: Department’s Project Manager Attn: _______________________________________________ From: _______________________________ _________________________ Name Title Project ________________________________ Region__________________ County ______________ Contract No. __________________ P.I.N. ________________________ Item _____________________ Construction QC Manager ______________________________ Design-Builder___________________ Gravel Source ___________________ Stockpile No. _____________________ Amount __________m3 Moisture Content at the Time of Mixing _____________________________% Asphalt Item Used in Mix ___________________________________ Recommended Application __________________________________L/m3 (Loose) Amount of Asphalt Applied __________________________________ L/m3 (Loose) Temperature of Asphalt in Tanker °C __________________________ Manufacturer of Pugmill: _________________________ Model or Serial No. ______________________ Continuous _____________ or Batch Type _______________ Twin Shift: Yes _______ No__________ Length of Mixing Area Beyond Point of Bituminous Application: ________________________________m Surge Hopper Capacity _________________ m3 or Dimensions: L ________ W _________ H ________ Bituminous Material Totalizing Meter: Yes ______________ No ___________________ Prime Distributor of Asphalt ____________________________________________________________ City ________________________________ Lot Number ______________ Width of Shoulders _______________________________ Layer Thickness ___________________mm Preliminary Curing Time ____________________________Roller Used _________________________ Location of Mixed Sample ______________________________________________________________ Observations and Comments ___________________________________________________________ ___________________________________________________________________________________

HC193a (DB)



JOSEPH H. BOARDMAN GEORGE E. PATAKI COMMISSIONER GOVERNOR

TO: Division Administration, Federal Highway Administration FROM: Regional Director of Transportation, Region SUBJECT: MATERIALS CERTIFICATION

F.A. PROJECT NO.: CONTRACT NO.: COUNTY:

DATE:

In accordance with the requirements of FAPG, 23 CFR 637B, Sampling and Testing of Materials and Construction, this is to certify that: The results of tests on acceptance samples indicate that the materials incorporated in the construction work, and the construction operations controlled by sampling and testing, were in conformity with the approved plans and specification requirements of the contract as evidenced by compliance with the Department's Quality Assurance Program as detailed in the Manual for Uniform Record Keeping and/or as stipulated in the specifications for each specific material. Also, comparisons between independent assurance sampling and testing for asphalt concrete, portland cement concrete, embankment, and subbase materials were satisfactorily conducted. Exceptions to the above have been explained by previous correspondence or are listed on the back hereof. Appropriate documentation covering materials used in the work and independent assurance samples pertaining to the work, are in the Department's files in accordance with the rules and policies of the Department as set forth in the Manual for Uniform Record Keeping and the Independent Assurance Sampling and Testing Procedure Manual. ____________________________________ Department’s Project Manager

R 45c (DB)

M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION

TO: Deputy Chief Engineer (Construction), Construction Division, 4-101 (MC0401) FROM: Regional Director, Region # SUBJECT: NOTICE OF FINAL INSPECTION / RECOMMENDATION OF CONTRACT ACCEPTANCE

CONTRACT NO. FED. AID PROJECT NO.

DATE:

On _______, the work covered by design-build contract no. ____________, County

of __________ , the design-builder being _____________________ was inspected

by ______________________, and the same was found to be completed in

accordance with the contract and specifications.

I, therefore, recommend that the same be ACCEPTED by the State Department of

Transportation and final payment made.

Signatures:

Regional Director Date

Additional Signatures as Required:

______ Director, Transportation Maintenance Date

______ Director, Highway Rail Unit Date

______ Others Date

The contract designated above is hereby ACCEPTED pursuant to the Highway Law.

_____ Deputy Chief Engineer Construction Date


HC 199 (8/73)

REQUEST FOR REESTABLISHMENT OF APPROACHES TO PRIVATE LANDS (Section 54-A, Highway Law) Region #____ State Highway #(s) __________ Contract # D __________ Town of ____________________ County of ____________________ The undersigned owner of private lands located on the __________ side of station __________

and the __________ side of station __________ and being further identified as _____________

hereby requests that the Department of Transportation cause the reestablishment of the

entrance, approach, or driveway on said lands to be adjusted to any new highway grade made

necessary by the construction or reconstruction of ___________________________ State

Highway No(s) __________ in accordance with Section 54-A of the Highway Law of the State of

New York, which provides as follows:

“54-A. Reestablishment of Approaches to Private Lands In the construction and reconstruction of any highway on the state’s system where a substantial change in the existing grade of the highway is made, such change making necessary the reestablishment of an existing entrance or approach to private lands, the Commissioner of Transportation may, upon the request of the abutting property owners affected, cause the reestablishment of the entrance, approach or driveway to be adjusted to the new highway grade and the cost thereof shall be a state charge payable from any money available for the construction or reconstruction of state highways. In such adjustment the details of the work shall be as determined by the Commissioner of Transportation. The state shall not be liable for the maintenance of such adjusted and reestablished approaches or driveways beyond the outside edge of the road shoulder nor shall it be liable for damages in connection therewith after the completion of such adjusted work.”

In Presence of: Dated: ____________ _____________________________ L.S.

Dated: ____________ _____________________________ L.S.

Dated: ____________ _____________________________ L.S.

State Of New York Department of Transportation

HC 90 (3/68)

PERMISSION TO RE-GRADE AND RE-SOD OR SEED LAWN Contract # _______________ State Highway # _______________ County _______________ TO: Commissioner of Transportation 1220 Washington Avenue State Campus Albany, NY 12226 The undersigned owner of private lands located on the _______________ side of the highway

at station _______________ and the _______________ side of the highway at station

_______________and being further identified as ____________________________________

hereby grants permission to the Commissioner of Transportation of the State of New York, His

agents or contractors, to re-grade and re-sod or seed the lawn on (my) (our) premises made

necessary by the construction or reconstruction of _______________ State Highway No.

_______________. This permission is granted with the understanding that such work shall be

limited to an area within ______________ feet of the highway right-of-way line. (I) (We) agree

that the State shall not be liable for the maintenance of such adjusted lawn area nor liable for

damages in connection therewith after the completion of the adjustment work.

Dated: ____________________________________

____________________________________ L.S.

Presence of:

____________________________________ L.S.

____________________________________ L.S.

____________________________________ L.S.


HC 90a (3/68)

PERMISSION TO REPLACE SIDEWALKS

Contract # _________ State Highway # __________ County _____________ Project Identification # __________ Federal Aid Project # _________ To: _____________________________ Commissioner of Transportation 1220 Washington Avenue State Campus Albany, N.Y. 12226

The undersigned owner of private lands located on the ______ side of the highway at station ____________ and on the ______ side of the highway at station ____________ and being further identified as __________________hereby grants permission and gives consent to the Commissioner of Transportation, the State of New York, his agents or contractors, to enter on to my (our) property in connection with the above referenced project for the purpose of replacing the existing sidewalk in front of my (our) property.

The undersigned owner(s) acknowledge(s) and waives my (our) right to just compensation in consideration of the benefits from said sidewalk replacement, and release(s) and hold(s) harmless the State of New York from any liability or damages which may arise subsequent to said sidewalk replacement.

Dated: _________________ In presence of: _____________________L.S. _______________________ _____________________L.S. _______________________ _____________________L.S.


HC 91b (11/78)

PERMISSION TO PLANT TREES AND SHRUBS Contract # _____________ State Highway # ________________ County __________________ Capital Project. Identification. # __________________ Federal Aid Project # _______________ The undersigned owner of private lands located on the _______________ side of the highway at

station ____________ and the ___________ side of the highway at station _____________ and

being further identified as ______________________________________ hereby grants permission

and gives consent to the Commissioner of Transportation of the State of New York, His agents or

contractors, to plant trees and shrubs on (my) (our) premises in connection with the construction,

reconstruction or improvement of ________________________ State Highway No.

_____________. This permission is granted with the understanding that such work shall be limited

to an area within _______________ feet of the highway right-of-way line. (I) (We) agree that the

State shall not be liable for the maintenance of such trees and shrubs beyond the period of one

year after planting work and maintenance period; and thereafter (I) (We) shall provide normal

maintenance. (I) (We) further agree that the New York State Department of Transportation may

enter (my) (our) premises, through said Department’s agents or contractors to perform normal

maintenance as required following the one year period after planting and that (I) (We) will obtain

written permission from said Department before causing said trees or shrubs to be removed.

Dated: ______________________________________

_____________________________________ L.S.

_____________________________________ L.S.

In Presence of:

________________________________ ____________________________________ L.S.

________________________________ _____________________________________ L.S.



JOSEPH H. BOARDMAN GEORGE E. PATAKI COMMISSIONER GOVERNOR TO: [Design-Builder] FROM: [Name of DPM] DATE: [Date] SUBJECT: Health and Safety Plan

In accordance with the Standard Specifications, this letter acknowledges receipt of the Project Safety and Health Plan as submitted by your firm for the above referenced Contract.

cc: [Name], Region [#] Construction Safety Coordinator


UTILITY POLES

POLE # CENTER

LINE STATION

SIDE OFFSET FROM

EXISTING

CENTERLINE MINIMUM

REQUIRED REMARKS


TRANSPORTATION MANAGEMENT CENTER (TMC)

FAX. NOS. (914) 949-4415 AND TEL. NO. (914) 949-3514 MAINTENANCE & PROTECTION OF TRAFFIC (MPT) REQUEST FORM PROJECT NUMBER: D - ROAD(S): COUNTY LOCATION(S): CONSTRUCTION AGENCY OR PERMIT OFFICE: REPORT FROM DATE TIME TELEPHONE NO. FAX NO. WHERE: (Specific Site - Cross Roads, Hamlet, Village, Towns etc.): DURATION OF TRAFFIC CONTROL MEASURES: (Days / Hours, Weekends, Nights) ______________ __________ _________________________________________________________________________

PROJECT DESCRIPTION: (Check all that apply) __Widening __Signs __Pavement Striping __Reconstruction __Maintenance __New Construction __Traffic Signals __Bridge Work __Guide Rails __Resurfacing __Safety Improvements __Other_______________ TRAVEL LANES NORMALLY AVAILABLE AT WORK SITE:

N/B: 1, 2, 3 OR ____ LANES E/B: 1, 2, 3 OR ____ LANES S/B: 1, 2, 3 OR ____ LANES W/B: 1, 2, 3 OR ____ LANES

TRAVEL LANES AFFECTED BY THIS CONSTRUCTION STAGE:

N / B, E / B: RIGHT LANE, LEFT LANE, CENTER LANE S / B, W / B: RIGHT LANE, LEFT LANE, CENTER LANE

MPT (Brief description of lane pattern / traffic stoppages & times): DELAYS (Expected Duration / Frequency) EXPECTED COMPLETION DATE: Total Project

This Construction Stage Begins Ends Project Approx % Completed

ADDITIONAL COMMENTS (AND / OR ATTACH COPIES OF PERTINENT RELEASES):


MURK 2b (DB-CCE) 1 of 2

CONSTRUCTION COMPLIANCE ENGINEER’S DAILY PROJECT DIARY

Page No. JOB STAMP Sheet No. of Sheets

Date Day of

Week S M T W T F S

Design-Builder's Work Hrs. AM PM Weather

MAJOR CONTRACT OPERATIONS High Low Temperature

I.R. No. CCM's Name Work Assignment and Identification

Maintenance of Traffic & Project Signs:

Remarks:


MURK 2b (DB-CCE) 2 of 2

Const. Compliance Engineer (Consultant) Consultant Firm Department’s Project Manager


MURK 2b (DB-DCE) 1 of 2

DESIGN COMPLIANCE ENGINEER’S DAILY PROJECT DIARY

Page No. JOB STAMP Sheet No. of Sheets

Date Day of

Week S M T W T F S

Designer's Work Hrs. AM PM

MAJOR CONTRACT OPERATIONS

I.R. No. DCM's Name Work Assignment and Identification

Remarks:


MURK 2b (DB-DCE) 2 of 2

Design Compliance Engineer (Consultant) Consultant Firm Department’s Project Manager


MURK 4d-DB(1) 1 of 2

Date: __________________

DEPARTMENT’S Day of the Week: ASPHALT CONCRETE DAILY FIELD INSPECTION REPORT

I. R. No.: _________________

Sheet No. ____ of _____sheets

Name of Paving Subcontractor (if any): ______________________________________

Price Center No. Station to Station Lane Length Width Course

Design Depth Area Weight

PRICE CENTER

PRICE CENTER

Tota

ls

PRICE CENTER

The above described work was incorporated into this Project and was inspected by:

____________________________ _____________________ ______ CCM Signature CCE Date

Dept. PM

S M T W T F S

SURFACE TEMPERATURE Start Finish Time Temp Time Temp

A.M. P.M.

JOB STAMP


MURK 4d-DB(1) 2 of 2

DEPTH CHECKS DEPTH CHECKS

Station Lane Uncompacted Depth

Course Station Lane Uncompacted Depth

Course

LABOR EQUIPMENT Type Prime Sub Sub Sub Sub Type Prime Sub Sub Sub Sub


NEW CONSTRUCTION PROJECT INFORMATION

The information you provide on this form will be used for the update of our Highway Construction Bulletin and the Internet Web Page.

Please Fax this completed form to (845)-949-4415 For additional information in completing this form, call (845)-949-3514 DATE: _____________________________________________________________ COUNTY: __________________________________________________________ ROADWAY: ________________________________________________________ TOWN / VILLAGE: ___________________________________________________ CONTRACT NUMBER: _________________START DATE: __________________ EIC / RE: _____________________________PHONE#:______________________ SCHEDULED COMPLETION: __________________________________________ PROJECT: _________________________________________________________ __________________________________________________________________ WORK ZONE: ______________________________________________________ __________________________________________________________________ TRAFFIC CONTROLS:________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ COMMENTS: _______________________________________________________ __________________________________________________________________ __________________________________________________________________




ORDER TO STOP WORK

JOB STAMP: Date: Location: Description of Problem: Delivered to: You are in direct violation of Section 619 of the New York State Specification and/or the New York State Manual of Uniform Traffic Control Devices in relation to the smooth and orderly flow of traffic and concern for public and pedestrian safety. You were thoroughly informed and familiarized with the required procedures, construction signs, traffic control devices, and flagman responsibilities at the Safety Meeting held on _______________. You were warned of this violation and directed to remedy the situation by N.Y.S.D.O.T. personnel assigned to the above project. Since you have failed to properly rectify the traffic control situation as noted above, you are hereby directed to cease all construction operations at this location and restore the area to original condition until the problem is remedied to the satisfaction of the Construction Compliance Engineer or Designer. With this notice a deduction will be assessed under Item 619.01 (Maintenance and Protection of Traffic) for this date and all subsequent calendars days until the proper traffic control and pedestrian safety are established. Signed By: ______________________________ Department’s Project Manager

M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: [ NAME ], Construction Division, 4-101, 0410 FROM: [ RCE NAME ], Regional Construction Engineer, Region [ # ] SUBJECT: ORDER-ON-CONTRACT TRANSMITTAL CONTRACT NO. D ___________________ DESIGN-BUILDER: _________________________________________ DATE:

Attached are _____ copies and an original of Order-On-Call No. _____ Resubmission No. _____ _____ Verbal approval to proceed with work is needed by ___________________________ _____ Verbal approval to proceed with work was given on __________ by _____________

Type of Order-On-Call _____ Administrative Change, no added work or additional funds _____ Regional Approval _____ Quantity incr./decr. existing items _____ Necessary Basic Project Configuration Change _____ Utility Information Error _____ Force Account Estimate _____ Clean up OOC using existing contract items to min. final pay. _____ Agreed Prices - Contractor requests the use of wt’d avg. bid prices _____ Agreed Prices - all Regional, M.O., and Contractor concurrences _____ Specification Change, rebate _____ yes _____ no _____ Agreed Prices - needs M.O. review: _____ Price _____ Tech. _____ Both _____ Force Account Actual _____ Contract Settlement, requires claim waiver _____ Value Engineering _____ Other: _________________________________________________ _____ This OOC does/will involve a Field Change Sheet, Nos. __________

Reason for Order-On-Call Transmittal

Unanticipated field conditions: _____ Structures _____ Highway _____ Drainage _____ Soils _____ Other _____ Design Error: _____ Consultant _____ Region _____ Design (M.O.) _____ Structures (M.O.) _____ Soils (M.O.) _____Materials (M.O.) _____ Traffic (M.O.) _____ Survey Error _____ Material Change _____ Requirements Contract _____ Betterment _____ M & PT Changes Comments: ________________________________________________________________________________________ ________________________________________________________________________________________


PERMISSION TO

_______________________________________ Contract No. __________ State Highway No. __________ County of _______________ Capital Project Identification # _______________ Federal Aid Project # _______________ The undersigned owner of private lands located on the ____________________ side of the highway at

station ____________________ and the ____________________ side of the highway at station

____________________ and being further identified as ______________________________________

hereby grants permission and gives consent to the Commissioner of Transportation of the State of New

York, His agents or Contractors, to enter upon (my) (our) premises in connection with the construction,

reconstruction, or improvement of ______________________________________________, State

Highway No. __________. This permission is granted with the understanding that such work shall be

limited to an area within __________ feet of the highway right-of-way line. (I) (We) agree that the State

shall not be liable for the maintenance of such area after the completion of Contract No. __________ nor

liable for damages in connection therewith. (I) (We) further agree that the New York State Department of

Transportation may enter (my) (our) premises, through said Department’s agents or contractors to

perform normal maintenance as required following the completion of Contract No. __________.

Dated:______________________________________

In Presence of:

_______________________________________

_______________________________________

_______________________________________

_______________________________________


PRICE CENTER - INTERIM PAYMENT

DATE

REF

ACTIVITY

%

ACTION

$

BALANCE

%

BALANCE

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M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: [ Name ], Contracts FROM: ____________________, Department’s Project Manager SUBJECT: EMERGENCY TELEPHONE NUMBERS D __________; PIN _______________ ____________________ COUNTY DATE: CC: [ Name ], Region # Traffic & Safety Group Will oversized or wide loads be restricted by a channeled traffic pattern (e.g., jersey barriers, closed shoulders)? YES* _______ NO ________ * If yes, complete memo (Form: Travel Restriction.doc) to Region # Permit Engineer Department’s Project Manager’s Name

Home Telephone: Project Address: City, State, Zip: Field Office Telephone: Project Mailing Address: (other than above)

Consultant Firm Name:

Resident Engineer’s Name: Home Telephone:

Const. Compliance Engineer’s Name:

Home Telephone: Design-Builder’s Name: Address: City, State, Zip: Telephone:

Traffic Signal Subcontractor’s Name:

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EMERGENCY CONTACT PERSONS

Worker Name Emergency Contact Person(s) Telephone Number

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M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: [ NAME ], Regional Design Engineer, Region [ # ] FROM: [ RCE NAME ], Regional Construction Engineer, Region [ # ] SUBJECT: R.O.W. MONUMENTATION [ D # ] [ PIN ] [ PROJECT DESCRIPTION ] [ COUNTY ] DATE: [ DATE ]

Placement of R.O.W. Monuments on the subject project is complete. [ # ] Monuments were placed. The required Surveyor’s Certification is attached. Surveyor: [ NAME ] License No: [ # ] Address: [ ADDRESS ] EIC: [ NAME ] Phone: [ # ] Address: [ ADDRESS ]

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JOB STAMP LAND SURVEYOR / EXEMPT P.E. SEAL

I hereby certify that the Right-of-Way Markers listed herein were installed in accordance and with the degree of accuracy required by Section 625 of the Standard Specifications of January 2, 2002 of the New York State Department of Transportation. Date _________, 20 _____ Signature _______________________ Lic.# _______

MAP ACTUAL

MAP #

BASELINE STA.

O/S L/R BASELINE STA.

O/S L/R TYPE

REMARKS

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M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: [Insert RCE Name], Regional Construction Engineer FROM: DPM, D25[xxxx] SUBJECT: RECOMMENDATION FOR FINAL ACCEPTANCE OF PROJECT (Release 70% of all Retainage ) [ D# ]; [ PIN ] FEDERAL AID PROJECT NO. [ # ] [ COUNTY ] DATE: [Insert Date] [Design-Builder’s Name] has completed work on the subject Contract as of [Last day of work]. All work completed to date has been done according to the Design Plans and Project Specifications. In accordance with Design-Build Section 109, the following have made a final inspection of the subject Contract and found it to be acceptable: [Supervisors name], Assistant Reg. Construction Engineer, [Date inspection was complete] [Resident Engineer. Name], Resident Engineer, [County], [Date inspection was complete] [Any other affected agencies], [Date inspection was complete] [Select Comment 1] There is no Uncompleted Work [or Comment 2] An Uncomplete Work Agreement and/or Striping Performance Bond is required for this Contract. Refer to the attached sheets. Based on the above, I recommend that this Project be accepted. Refer to the attached contract status checklist for additional project information. cc: [Supervisor’s name], Assistant Construction Engineer Project Files

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[ D# ]

CONTRACT STATUS CHECKLIST The following information relates to the current status of the contract at the time of the DPM’s recommendation for final acceptance: 1. ORDERS-ON-CONTRACT

If none, check here

Approved - # thru # $ _________ Recommended - # thru # $ _________ Pending - # thru # $ _________

2. PROJECT COMPLETION DATE (same date as submitted on HC-136) Last Day of Work 3. EXTENSIONS OF TIME

If none check here, ________

(a) With Engineering Charges until _________________ # of Extensions Amount of Charges $ _______ (b) Without Engineering Charges ___________________

# of Extensions ______________________________ (c) Liquidated Damages assessed $__________________

4. CHARGES / CREDITS If none, check here

(a) M & P of Traffic Charges assessed $ ______________ (b) Safety/Other Charges assessed $ _________________ (c) Asphalt/Concrete out of tolerance credits # of Credits ________ Amount $________________

5. UNCOMPLETED WORK AGREEMENTS (Not applicable for safety related items)

If none check here

(a) Period of Establishment - 611 Items (trees planted?) yes no___ (b) Total 611 Item $__________ (c) Unsatisfactory stand of grass - 610 Item (grass planted?) yes no___ (d) Total $____________ (e) Misc. Items $ amount ___________________

(Misc. description) _____________________ 6. TRAFFIC CONTROL DEVICES (Item 680's) If none check here

(a) Attach Final Inspection Letter sent to Traffic. (b) If Strain Poles (Items 680.60xxxx) were used check here _____ Were the Drawings and Tracings approved? Yes No______ (c) If Preformed Pavement Markings (Items 18688.xxxx) were used

check here and notify the Design-Builder to submit the required bonds (see item description) to the Regional Office.

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This recommendation will not be forwarded to Albany until the bonds have been received in the Regional Office. Actual last day of Installation of Markings _______________ (d) Were there any overhead or cantilevered sign structures?

Yes No Were the shop drawings approved by Regional Office? Yes___ No ___

7. CORES

If none were taken check here _______

(a) If satisfactory, check here _________ (b) If unsatisfactory, check here ________ action taken

8. BRIDGES If no bridges were involved, check here Attach Final Inspection memorandum submitted to Structures. 9. OFFICIAL DETOURS

No Official Detours used check here An Official Detour was used check here 10. AFFECTED AGENCIES (Maintenance, Counties, Towns, Villages, FHWA) Attach copies of Final Inspection letters sent to these agencies. 11. RESTRICTED HIGHWAY

Highway(s) was/were not restricted check here Highway(s) was/were, enter original restriction date

12. RIGHT-OF-WAY

Check here if there was a TO or a TE All work completed within these areas? Date of Completion 13. INTERIM PAYMENT

Is Price Center _____, Interim Payment _____, zeroed out? Yes No If no, is the clean up order submitted? Yes No 14. RECORD PLANS / AS BUILTS

To whom were they submitted? (per CAM) Date: 15. DATE OF ACTUAL INSPECTION - by whom

M E M O R A N D U M

STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: [ RCE NAME ], Regional Construction Engineer, Region [ # ] FROM: [ DPM NAME ], [ D# ] DATE: [ DATE ] SUBJECT: [ D# ] [ PROJECT DESCRIPTION ] Release of Uncompleted Work Agreement

This memo is to inform you that I have inspected the following Items for the Uncompleted Work agreement on [ DATE ] and found them to be within specification tolerances. At this time, the Uncompleted Work Agreement Monies can be released.

[ LIST ALL ITEMS WITH DESCRIPTIONS ] cc: Project Files

M E M O R A N D U M

NEW YORK STATE DEPARTMENT OF TRANSPORTATION TO: Regional Real Property Officer, Region [ # ] FROM: [ NAME ], Department’s Project Manager SUBJECT: REPORT OF DESIGN-BUILDER’S INITIAL ENTRY UPON NEW ROW PARCELS DATE: [ DATE ]

P.I.N. _______________ CONTRACT # _________________ PROJECT: ___________________________________________ MAP(s) ______________ PARCEL(s) _________________ REPUTED OWNER: _____________________________________

The project design-builder entered upon and occupied the above designated right-of-way parcel(s) for the first time on __________________, 20 ____ and such entry was for purposes of construction as checked below:

G Clearing and Grubbing G Grading G Drainage Work G Use of ROW parcel for access to other areas for contract work G Other purpose (briefly describe): (Submit original only to Regional Real Property Officer)

STATE OF NEW YORK

DEPARTMENT OF TRANSPORTATION ALBANY, N.Y. 12232

http://www.dot.state.ny.us JOSEPH H. BOARDMAN GEORGE E. PATAKI COMMISSIONER GOVERNOR [Insert Date] RE: D25[xxxx] PIN [xxxxxx] [ Insert Project Description] Dear [Insert Design Builder’s Name], We have received your written request to proceed at risk on the referenced agreement and authorize you to start work on [Insert date]. Time and charges can be accrued to the project and progress estimates must be submitted to the Department’s Project Manager, however, payment can not be made until the Agreement is fully executed by the Comptrollers Office. In the unlikely event this agreement is not approved by the Comptrollers office, the Department will be unable to pay for some or all of the services provided.

Sincerely,

[ Insert Name ] cc : (Contract Analyst), Contract Management Bureau, 5-108 J. Tynan, Construction Division, 4-101 MC 0410

M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: Permit Engineer, Region [ # ] FROM: [ NAME ], Department’s Project Manager SUBJECT: TRAVEL RESTRICTION ON ROUTE [ # ] BETWEEN ROUTE [ # ] AND ROUTE [ # ] [ D# ] [ PROJECT DESCRIPTION ] [ COUNTY ] DATE:

RESTRICTION: ( ) Seasonal ( ) Posted Bridge ( ) Posted Road ( ) Constr. Project

If a bridge, bridge crosses __________________________________________ COUNTY: _______________ TOWNSHIP: _______________ MAX WEIGHT: _______________ MAX WIDTH: _______________ MAX LENGTH: _______________ MAX HEIGHT: _______________

ALTERNATE ROUTE:_____________________________________________________

_______________________________________________________________________

____________________________________________________________________ This restriction will remain in effect until ___________________ (Approx. Date)

DPM: [ NAME ] Telephone: [ # ] RESTRICTION RESCINDED: This restriction went into effect per memorandum dated___________________ This restriction is rescinded effective__________________________________ ( ) MAP ATTACHED NOTE: Submit this memo when placing the restriction in effect AND

submit the same from when the restriction is rescinded.

Bridge Status

M E M O R A N D U M STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION

TO: [ Name ], Regional Bridge Management Engineer, Region [#] Attention: [ Name ], Bridge Inventory Engineer FROM: __________________________, Department’s Project Manager SUBJECT: D______

STATUS OF BRIDGE UNDER CONSTRUCTION DATE: The following bridge was closed/opened (circle one) on _________________________________: B.I.N.: ______________________________ COUNTY:___________________________

The bridge is a:

new ) replacement ) circle one rehabilitation )


STATUS OF SUBCONTRACTORS

Project # D __________

Name & Address Date on AAPHC 89 First Day of Work

Last Day of Work

Date on AC 2948

Is Sub Finished?


SUBCONTRACTOR EVALUATION FORM CONTRACT _______________________ SUBCONTRACTOR_______________________________ DESIGN-BUILDER __________________________________________________________________ DATE_______________________ DEPARTMENT’S PROJECT MGR. _____________________ AREA SUPERVISOR_______________ SUBCONTRACTOR'S ITEMS OF WORK _________________________________________________ WBE: Y N _______________________________________________________________ DBE: Y N _______________________________________________________________ 1. Did the subcontractor begin work on time and continue working on schedule so that other work was not delayed? Y N 2. Did the subcontractor appear to be familiar with Plans, Proposals and

Specifications? Y N 3. The subcontractor performed work with: (own work force) (prime's work force) or

(combination)? 4. The name of the subcontractor superintendent is _____________________________________. 5. The equipment used by the subcontractor was: (leased by sub) (owned by sub) or (combination). 6. Was effective communication between the subcontractor and yourself maintained

throughout the contract? Y N 7. Did the subcontractor follow NYSDOT safety and maintenance & protection of traffic policies and procedures? Y N 8. Did the subcontractor meet hiring goals? Y N 9. Based upon your observation of their work performance, what is your rating of the subcontractor? Poor Excellent 1 2 3 4 5 10. Based upon your observation of the subcontractor's performance, would you recommend them

for future work? YES______ NO_____ WITH RESERVATIONS_____ COMMENTS:_________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


Form TE-200c 2/99

CONTRACT NO. FISCAL SHARE NO. PG. NO. TRAFFIC SIGNAL EQUIPMENT FURNISHED BY NEW YORK STATE DEPARTMENT OF TRANSPORTATION

EQUIPMENT SUMMARY F.A. PROJECT NO. ENGINEERING SHARE NO. TOT. PGS. NOTE: SHADED AREA TO BE FILLED IN BY MAIN OFFICE DESCRIPTION:

LETTING DATE

P.I.N.

REGION

M.O. TRAFFIC & SAFETY

DEPARTMENT’S PROJECT MANAGER

MODEL #

DESCRIPTION

UNIT EST. QTY.

UNIT

PRICE

ESTIMATED

AMOUNT

FINAL QTY.

FINAL

AMOUNT

DIFFERENCE

+ OR - CABINET/CONTROLLER ASSEMBLY INCLUDES:

179 MICROPROCESSOR UNIT EA.

204 SOLID STATE FLASHER RELAYS EA.

210 SOLID STATE MONITOR MODULE EA.

215

CURRENT MONITOR EA.

330

TRAFFIC CABINET/HARNESS EA.

200

SWITCHPACKS EA.

222

DUAL LOOP VEHICLE DETECTORS EA.

231

MAGNETIC DETECTOR PROBE EA.

232

DUAL MAGNETIC DETECTOR AMPLIFIER MODULE EA.

242

DUAL DC ISOLATION MODULE EA.

252 DUAL A.C. ISOLATION MODULE EA.

400 MODEM MODULE/INTERCONNECT HARNESS EA.

TOTALS

Expenditure Codes

Dept/Div

Fund

Yr/Bill

MP

MO

SP SO

1700

1700

This certifies the above final quantities were supplied by N.Y.S. and incorporated into the work DEPARTMENT’S PROJECT MANAGER DATE____________

T R A N S M I T T A L STATE OF NEW YORK DEPARTMENT OF TRANSPORTATION TO: FROM: [ NAME ], EIC SUBJECT: [ D# ] [ PROJECT DESCRIPTION ] DATE: CC: To Whom It May Concern: We are sending you: ( ) Attached ( ) Under Separate Cover ...via ______________________________ ( ) Plans ( ) Approval of Subcontractor ( ) Photographs ( ) Report ( ) Specs ( ) Order-on-Contracts ( ) Copy of letters ( ) Cross Sections ( ) Form ______________________ ( ) Other _________________________________________________

Copies Date Number Description

These are transmitted as noted below: ( ) For approval ( ) Approval as submitted ( ) Resubmit ____ copies for approval ( ) For corrections ( ) For Info ( ) Approved as noted ( ) Resubmit ____ copies for distribution ( ) For action ( ) Return ____ corrected prints ( ) As requested ( ) For review/comments REMARKS: _______________________________________________________________________ _______________________________________________________________________

IF ENCLOSURES ARE NOT AS NOTED, PLEASE CONTACT ME AT ONCE.


UTILITY MEETING MINUTES

[ Day - Date - Time ] [ D # ] [ PIN ]

[ Project Description ] ATTENDEES: Name Representing Title Phone # TOPICS DISCUSSED: 1.


VALUE ENGINEERING CHANGE PROPOSAL SUMMARY

VECP SUBMISSION DATE: VECP SUBMISSION (Check One): Conceptual Formal Joint Conceptual & Formal CONTRACT INFORMATION CONTRACT D#: _______________________ LETTING DATE: ___________________ PIN: _________________________________ ORIGINAL CONTRACT BID: $ ________ DESCRIPTION: ________________________ REGION: COUNTY: ________________ FEDERAL AID #: CONTRACTOR: ___________________________________________________________________ VECP INFORMATION SHORT DESCRIPTION OF VECP: (A) TYPE OF VECP? (Check One): COST SAVINGS TIME SAVINGS ONLY (B) IS THERE A DATE BY WHICH THE VECP WORK MUST BE AUTHORIZED?: YES NO DATE? : _________ (C) ANY NEW OR EXISTING PAY ITEMS REQUIRING AGREED PRICES?: YES NO HOW MANY? : ____ (D) ANY PAY ITEMS WITH LONG LEAD TIMES THAT REQUIRE APPROVAL?: YES NO HOW MANY? : ____ (Note : Describe items A. through D. in further detail in ‘COMMENTS’ as appropriate.) (E) CONTRACT COST W/O VECP: $ __________ (Note: this is the latest cost as of the VECP submission date) (F) CONTRACT COST W/ VECP *: $ __________ (* Note: Excludes any VECP savings or design cost

reimbursements) (G) VECP CONSTRUCTION SAVINGS: $ __________ (Note: Equals item E. minus item F) (H) VECP DESIGN COST: $ __________ (I) DIRECT COST SAVINGS: $ __________ (Note: Equals item G. minus item H) (J) NET SAVINGS TO STATE: $ __________ (Note: Equals 0.5 times item I) (K) TOTAL ADJUSTED CONTRACT COST: $ __________ (Note: Equals item E. minus item J) (L) VECP SAVINGS REIMBURSEMENT TO CONTRACTOR : $ ___________ (Note: Equals 0.5 times item G) (M) VECP DESIGN REIMBURSEMENT TO CONTRACTOR: $ ___________ (Note: Equals 0.5 times item H) COMMENTS 1. ________________________________________________________________________________

_______________________________________________________________________________ 2. _______________________________________________________________________________


JOB STAMP

Wage Rate

Interview Form __________________________________________________________________________________ PART I - To Be Completed During Interview Employee Name _________________________________________ ___________ Print Date Title/Job Classification (as stated by employee) ___________________________________ Is the employee aware that they are entitled to receive prevailing wages and supplements? YES ___ NO ___ Hourly Rate (as stated by employee) ________________________ Does the hourly rate include fringe benefits? YES ___ NO ___ If no, what are the fringe benefits ________________________________________________ Company issuing employee’s check _______________________________________________ Employee Signature ________________________________________________________ Comments: __________________________________________________________________ __________________________________________________________________________________ PART II -To Be Completed After Interview Is employee doing work per job classification? YES ___ NO ___ Interviewed By __________________________________ __________________________ Signature Date of Interview Comments: ____________________________________________________________________ __________________________________________________________________________________ PART III - To Be Completed In The Field Office Rate verified by: Hourly Rate of employee per payroll for interview date _____________ ____________ Prevailing Rate for interview date( NYS or FED. Gov’t) _____________ ____________ whichever is higher Comments: ____________________________________________________________________

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JOSEPH H. BOARDMAN GEORGE E. PATAKI COMMISSIONER GOVERNOR [ Current Date ] [ Design-Builder] [ Address ] [ Town, State ] Re: Waiver of MSDS Requirement [ Contract D# ] [ Project Description ] Attn: [ Design-Builder’s Project Manager ] Gentlemen: Pursuant to Section 106-01 of the Standard Specifications, this is to notify you that the requirement to provide a Material Safety Data Sheet (MSDS) is waived on this project for the materials named on the enclosed list. You are required to provide me an MSDS for all other materials to be used or encountered in the work to the extent that an MSDS is required by OSHA Part 1926.59 regulations. You are reminded that you are required to maintain at the project office an MSDS for all materials to be used or encountered in the work before any such material is used. This includes all materials as defined in OSHA Part 1926.59, both those on the enclosed list and any other materials to be encountered or used in the work. Very truly yours, ________________________________ Department’s Project Manager Enclosure cc: [ RCE Name ], Regional Construction Engineer

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LIST OF WAIVED MATERIAL SAFETY DATA SHEETS

Acetylene

Asphalt Cement

Asphalt Emulsions

Calcium Carbonate (Limestone)

Calcium Hydroxide (Lime Products)

Calcium Chloride (Road Salt)

Carbon Monoxide

Coal Tar Emulsion

Concrete Sand

Creosote

Diesel Fuel

Ethylene Glycol (Antifreeze)

Gasoline

Iron

Kerosene

Lead

Lubricating Oils

Motor Oil

Oxygen

Portland Cement

Propane

Silica

Sodium Chloride (Rock Salt)

Wood Dust

Zinc

Form 619-5




[ Date ]

RE: [ D # ] [Project Description]

ATT: [ Design-Builder ]

Dear Sir:

Please be advised that as of this date all terms of Section 619-5, BASIS OF PAYMENT, of the Standard Specifications of January 2, 2002 shall be strictly enforced. A breakdown of charges are in the amount of [ YOUR AMOUNT ] /calendar day; liquidated damages of [ YOUR AMOUNT ] /day for each subsequent calendar day or part thereof. Please be advised that you are being charged the amount of [ YOUR AMOUNT ] on this date for numerous violations. I have spoken to your superintendent about these violations and he is now working to correct the problems. If you have any questions, please contact me at the field office, [ YOUR NUMBER ] Respectfully, [ Your Name/DPM D# ]

cc: file [ Your Supervisor ], Assistant Regional Construction Engineer [ Name ], Regional Construction Safety Coordinator

VOLUME V OF V DESIGN-BUILD PROCEDURES MANUALEXHIBIT V FORMS FOR DEPARTMENT USE

DDEESSIIGGNN--BBUUIILLDD PPRROOCCEEDDUURREESS MMAANNUUAALL · the Design-Builder’s schedule, or...

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