2013
Construction Inspection Guide Appendix: Construction Forms
Construction Division
Utah Department of Transportation
Table of Contents - Construction Forms Construction Administration Forms
Civil Rights Forms - Federal Aid Project
C-115
C-130 OJT
Request to Sublet
Training Commitment Form
Contractor/Subcontractor Certification Federal Aid Projects
EEO Bulletin Board Inspection
C-116
C-131 C-133
Harassment, Intimidation & Coercion
C-136
Labor and EEO Interview
Contract Agreement Forms C-100
Change Order Short Form
C-101
Change Order Attachment A
C-102
Change Order Attachment B
C-103
Cost Analysis/Itemized Statement
C-104
Daily Force Account Cost Report
C-104
Weekly Force Account Cost Report
C-107
Authorization to Proceed
C-114
Signature Sheet
C-138
Final Payment Checklist
C-139
Training Hours Reimbursement Affidavit (Prime)
C-139A
Training Hours Reimbursement Affidavit (Sub Contractor)
C-141
DBE Commercially Useful Function (CUF)
CR-257
Utilization Report (Hours)
1444
Request for Authorization of Additional Classification and Rate
WH-347
Payroll Forms/Compliance Certification
FHWA 1391
Workforce on Federal-Aid Projects
C-118
Construction Overrun Funding Need (COFN)
C-118U
Utility Contract Overrun Funding Need (uCOFN)
C-119
Contractor Performance Rating
C-193
Utility Fiscal Review Report
C-193A
Utility Salvage Report
C-300
Fuel Cost Adjustment
C-302
Asphalt Cost Adjustment
R-5
Transfer of Materials & Equipment
Tool Box Forms DBE Hold Harmless Agreement Monthly OJT Report Form Monthly OJT SS Reimbursement Form Monthly Exp. Report EEO and Labor Complaint Form Complaint Procedure (Exhibit – A) Annual Training Reconciliation Report Example Submittal Log Example RFI Log Example Action Log FHWA 1273 Helpful Link: DBE Request Form
Table of Contents - Continued Inspection Forms ATMS 5-Day Testing Pre-Notification ATMS 30-Day Burn-in Test Report ATMS Cable and Conductor Test ATMS Completion Notification FOT CCTV FOT inductive Loop
Construction Materials Forms C-247
Request for Testing
C-513
Paint Sample Identification Form
C-348
Weekly Density Report
C-258
Aggregate Physical Properties Report
C-251
Concrete Cylinder Test Report
C-350
Density Test Summary
C-112
Detector Accuracy Verification Test - Volume
Crash Cushion, Barrier End Treatment Certification Letter
Detector Accuracy Verification Test - Occupancy
Notice of Unacceptable Work or Materials
FOT Non Intrusive Detectors
FOT Non Intrusive Detectors
C-106
FOT Non Intrusive Detectors
C-520
FOT Non Intrusive Detectors
C-500
Smart Sensor 105 Rolling Average Speed Test Smart Sensor HD Rolling Average Speed Test
Concrete Placement Log Buy America Foreign Steel Tracking Federal Aid Projects
FOT Ramp Meter FOT VMS FOT WIM C-111
Inspector’s Daily Report
C-120
Construction Process Review Report
C-150
Culvert Inspection Form
C-160
Visual Inspection Form
Construction Closeout Forms C-127
Final Estimate Package Check Sheet
C-128
Report on Assembly of Final Estimate
C-190
Project Acceptance Report – Substantial, Physical and Contract Completion
C-196
Project Materials Certification
C-196A
Attachment A
C-197
Required Final Project Documentation Checklist
C-199
Post Construction Conference Report
C-200
Certificate of Receipt & Release
Construction Inspection Guide
Construction Administration Forms
UDOT Form No. C-115 (Revised 8/02)
Request to Sublet Work
Utah Department of Transportation
Subcontractor
Lower Tier Subcontractor
1. Prime Contractor
2. E-Mail Address
3. Project No.
4. Phone No.
6. Project Description (Title)
7. Original Contract $ Amount $
Approval is Requested to Sublet the Following Described Work.
5. Fax Number
(Completed by Prime
8. Subcontractor or Lower Tier Subcontractor
9. E-Mail Address
10. Address
11. Phone No.
13. City
State
Zip
15. If Lower Tier Subcontractor, Identify Corresponding Subcontractor(s)
17. Item No.
14. Estimated Starting Date 16. Subcontract No.
Item Description
Partial
12. Fax Number
(If Partial - Indicate precisely the work to be performed by the Subcontractor)
Amount
(Indicate $ Amt. for each item)
Actual $ Amount of Subcontract
I will insure the subcontractor=s compliance with the plans and specifications under which this work is be performed.
/
Contractor=s Signature
/
Date
$0.00
By signing this form, I agree to complete the items of work identified on this form in accordance with the plans and specifications for this project. A copy of the subcontract agreement will be provide to UDOT when requested. /
Subcontractor or Lower Tier Subcontractor
/ Date
This Area for Department of Transportation Use Only 18. Percent of Total Contract (Based on CSI Specification 00555, 1.3, A-G) Total $ Request to Sublet:
This Request:
%
$ Amount Spec. Items:
Sublet to Date:
%
(Fill in information from PDBS_Project Administration_Data Entry_Subcontracts) 20. Approved by Resident Engineer: Signature:
19. DBE Committed Amount $ Race Neutral (Check both if applicable)
21. Reviewed in Region By: Date
/
/
Signature:
Distribution: 1 - Construction Division (Original Signatures), 1 - Region, 1- Resident Engineer 1 - Contractor.
Date
/
/
C-115 CONTRACTOR INSTRUCTIONS
3-03
TO BE COMPLETED BY THE PRIME CONTRACTOR; Check (X) Subcontractor Box or Lower Tier Subcontractor Box in upper right corner. No. 1
Prime Contractor Contractor is to use same name used when project was bid.
No. 2
E-Mail Address Contractor=s e-mail address for contact person.
No. 3
Project No. Exact project number as it appears on the Contract Special Provisions, including the asterisk if applicable.
No. 4
Phone No. Contractor=s phone number for contact person.
No. 5
Fax Number Contractor=s fax number for contact person.
No. 6
Project Description (Title) The name of the project as it appears on the Contract.
No. 7
Original Contract $ Amount B Total original Contract dollar amount.
No. 8
Subcontractor or Lower Tier Subcontractor The complete business name of the subcontractor=s firm. OR: The complete business name of the lower tier subcontractor. NOTE: If a lower tier subcontract, No. 8 through 14 shall be the lower tier subcontractor=s information.
No. 9
E-Mail Address The subcontractor=s e-mail address for contact person. Enter Anone@ if there is not an e-mail address.
No. 10
Address The subcontractor=s current street address. P.O. Box number may be included.
No. 11
Phone No. The subcontractor=s phone number for contact person.
No. 12
Fax Number The subcontractor=s fax number for contact person. Enter Anone@ if there is not a fax number.
No. 13
City
No. 14
Estimated Starting Date The estimated date the subcontractor is expected to begin work. OR: The date the lower tier subcontractor is expected to begin work.
No. 15
If Lower Tier Subcontractor, Identify Corresponding Subcontractor(s) The complete firm name of the original subcontractor who is subletting work to the lower tier subcontractor.
No. 16
The Prime Contractor is to consecutively number each C-115 starting with 1.
No. 17
Item No. is the original bid item number in the bid item list in the Contract. Partial Column B Indicate in this column if subcontractor is to perform only part of work required to complete the bid item. Item Description is the exact description of the original bid item in the bid item list in the Contract. If the work is APartial@, describe below the item description just the work to be performed by the subcontractor. NOTE: Enter Change Order number, exact Item No. and Item Description from Change Order if subcontract is for change order work. Change Order work is not calculated into Percent of Contract sublet. Amount is the agreed total dollar amount between the Prime Contractor and the subcontractor for each item. OR: Amount between the subcontractor and the lower tier subcontractor. Actual $ Amount of Subcontract is the total dollar amount for all item amounts listed in the Amount column.
State Zip The full name of city, state and complete Zip Code.
Contractor=s Signature & Date Must be original signature and date C-115 is signed. OR: Original signature and date of subcontractor subletting the work to lower tier subcontractor. Subcontractor or Lower Tier Subcontractor signature and date Must be subcontractor=s original signature and date C-115 is signed. OR: Must be the original signature of the lower tier subcontractor and date signed. For Federally Funded Projects Only - NOTE: No. 19 DBE B COMMITTED AMOUNT $ Items listed in No. 17 must be same as listed in the Bid DBE Commitment. Amount for each item must be same amount or greater than Amount listed in the Bid DBE Commitment. No. 19 is to be reviewed and completed by the UDOT project office.
UDOT Form No. C-116 Rev. 10/12
Subcontract Agreement Certification for Federal-Aid Projects
Utah Department of Transportation
1. Project No(s).
(Required for each subcontractor or Lower Tier Subcontractor on all Federal-Aid projects)
2. Project Description (Title)
3. Subcontractor or Lower Tier Subcontractor Certification Signed by proposed subcontractor or lower tier subcontractor.
The contract documents for this subcontract include as part of the subcontract required Federal-aid provisions entitled Attention Contractors, Specific Equal Employment Opportunity Responsibilities, Bid Conditions, DBE, Required Contract Provisions FederalAid Construction Contracts (FHWA 1273), Buy America (Standard Specification 01455), and the minimum wage rates. I certify the above statement to be true and correct.
Company By
(Signature)
Date
/
/
Title 4. Contractor Certification Completed and signed by the Contractor.
1.
A written agreement has been executed between my firm and the above subcontractor
2.
A written agreement has been executed between (the subcontractor): and the above lower tier subcontractor.
All documents required by the special provision entitled Required Federal-Aid Provisions are included in the agreement for (1) or (2) marked above. I certify the above statements under Contractor Certification to be true and correct.
Company By
(Signature)
Date
Title Distribution:
1- Construction Division (Original Signatures), 1 - Region, 1 – Resident Engineer 1 - Contractor
/
/
C-116 CONTRACTOR INSTRUCTIONS FOR FEDERALLY FUNDED PROJECT ONLY 1.
Project Number(s) is the Project Number(s) as it appears on the Contract Special Provisions, including the asterisk if applicable.
2.
Project Description (Title) is the name of the project as it appears on the Contract.
3.
Company is the complete business name of the subcontractor’s firm. OR: The complete business name of the lower tier subcontractor. Note: All contract documents listed on the C-116 are to be attached to and will become part of the subcontract agreement. Note: Assurances and Inclusions required by Special Provision, Bid Conditions, Disadvantage Business Enterprise (DBE), Section 00555 Prosecution and Progress, 1.4 Subletting Contract and Section 01284S Prompt Payment must be included in the subcontract agreement. By Must be the original signature of the subcontractor. OR: Must be original signature of the lower tier subcontractor. Date is the date the C-116 is signed by the subcontractor. OR: The date the lower tier subcontractor signs the C116. Title is the title of the person signing the C-116 in Section 3.
4.
Contractor Certification This section is to be completed by the Prime Contractor. 3.1 Box is to be checked when the C-115 is between the Prime Contractor and a Subcontractor. 3.2 Box is to be checked when the C-115 is between a Subcontractor and a Lower Tier Subcontractor. Company is the Prime Contractor’s name used when project was bid. By Must be an original signature of the Prime Contractor. Date is the date the C-116 is signed by the Prime Contractor. Title is the title of the Prime Contractor’s representative signing the C-116. C-116 with Original Signatures is to be attached to the C-115 with Original Signatures and forwarded to the Resident Engineer for the project. Subcontractors are not allowed to work on the project until the project office reviews the C-115 and C-116 and the Resident Engineer signs the C-115.
Construction Inspection Guide
Contract Agreement Forms
Electronic Change Orders The Change Order forms C-100, C-101 and C-102 should be created using PDBS. Instructions on entering this information into PDBS are attached. The old C-101 and C-102 are also currently available on the web for your convenience but the information must also be entered into PDBS and the forms should be generated there. Electronic Change Orders were created to minimize the user input required by PDBS, minimize calculation/entry errors, and provide autocompletion of forms. Once the change order has been approved, PDBS will add or modify bid items within Project Acctg., DBE commitment changes in Civil Rights, and update Utility agreements . Forms can be printed and circulated for signatures. Hard copies and Original signatures are still required for our files.
Start process by Right clicking on the Change Order folder and selecting ‘New’.
Select Change Order Type
Select Change Order type‌Contractor or Utility Company
Initial Entry Screen
New data window..Must enter Description, Group/Alpha/Origin Codes, Basis of Payment and Save. If extending contract time, add it now if possible.
Initial Entry Screen with Required data
New data window..Required fields; Description, Group/Alpha/Origin Codes, Basis of Payment. Save or click ‘Change Order Form’.
Create C-100 from this screen.
Adding an New Detail
Add Detail box..Select Yes to add an existing Detail. Select No to add New Detail
Add Existing Detail
Add Existing Detail…select from dropdown.
Add Detail popup
Add New Detail window..Select Description…add Extended Description..click OK.
Add New Item
Add new item popup‌Select Yes to add existing and no to add a new item from Standard or Unique item lists.
Add New Item popup
Add item from Standard list‌click on Search. Or, select Unique Item and search Unique item table.
Item Lookup Table
Item lookup table…add one item at a time.
Future enhancement will allow for selection of multiple items.
Add New Item - Surveying
Add item –Description, unit price, quantity, Unit of Measure.
C-100 with New Item
New item is added to Change Order..note original quantity is ‘0’. Quantity Change +/shows revision to be made.
Adding Existing Item
Adding an existing item…select from dropdown list.
Existing Item – Enter Quantity change
Enter Changed Quantity +/-. This is how much you want to change the current quantity. Do not include Current Quantity here.
Screen view with new items
Completed change order items‌ready for viewing/printing. Click on the C100 Change Order Button
C-100 Form – Top Section
View and print the C-100 from here.
ATTACHM ENT A
Form C101 Rev. 10/03
TO CONSTRUCTI ON CONTRACT CHANGE ORDER NO.
PAGE 1 OF
PROJECT NO.:
LOCATI ON:
LETTER OF EXPLANATI ON REASONS FOR CHANGE ORDER:
PROJECT ENGINEER'S COST ANALYSIS:
CONTRACT TIME ADJUSTMENT:
COORDINATED WITH:
ATTACHM ENT B TO CONSTRUCTION CONTRACT CHANGE ORDER NO. PAGE 1 OF PROJECT NO.:
LOCATION:
SPECIAL PROVISION PROVISION:
Form C102 (10/03)
Page 1 of (X one)
or Itemized Statement
Cost Analysis
C103 - 2012 Spec. Revised 02/12
Project No.: Location: Contractor :
Change Order No.:
Charge ID No.: Contract Date:
Labor: (Use Wage Rates of Contractor, if applicable) Name
Classification
What is C103 For: Pay Rate
Frng
Reg Hours
O/T Hrs
Amount
Rate
% Tax
Amount
Labor Costs (Plus 15% per contract provisions. Refer to Standard Specifications)
MATERIALS: (Attach invoices or weigh tickets) Description
Invoice or Tickets
Quantity
Unit
Materials Cost (Plus 15% per contract provisions. Refer to Standard Specifications)
Equipment: (Lesser of Rental Rate Blue Book {Hourly Rate = Monthly Rate/176} OR Actual Contractor Equip. Cost) Standby Calculations
Equipment Designation Description
Yr
Ownership Rates
Hours Standby
Operating Calculations Operation + Ownership
Hours Operate
Mobilization Cost (For Equipment not already on project. Refer to Standard Specifications)
Equipment Costs Subtotal (Labor + Materials + Equipment) If Subcontract add 10% for the first $5,000 and 5% for balance in excess of $5,000. (place x)
Grand Total = Note: Cost Analysis - attach to Change Order Itemized Statement - attach all supporting documentation and submit with final estimate All Calculations on Excel
Amount
C-104 Daily Form Rev. 11/12
Daily Labor, Materials, and Equipment Record
Date:
*Work Summary:
Project No.: Location: Contractor/ Utility:
LABOR Name
Classification
Reg. Hrs.
O/T Hrs.
Total Hrs.
Total Labor Hours
MATERIALS Description
Quantity
Unit
EQUIPMENT: Equipment Description
Ref. No or License Plate
Hrs. of Operation
* Brief summary of work performed by contractor. Also, indicate actual location within the project where work was performed.
Comments:
Approved by Contractor/ Utility Representative: Contractor/Utility Representative
Approved for UDOT: Date
UDOT/IQF Representative
Date
C-104 Weekly Form Rev. 11/12
WEEKLY LABOR, MATERIALS, AND EQUIPMENT RECORD
Project Number
Agreement No.
INSTRUCTIONS: Labor & equipment hours must be verified and initialed
by the Contractor/Utility in the daily space provided. Retain original copy in project files. Provide one copy for Contractor/Contractor.
Location: Contractor/Utility: Subcontractor: Description of Work:
LABOR
DATES AND HOURS
TOTAL HOURS
NAME AND CLASSIFICATION SUN.
ST.
MON.
O.T.
ST.
TUES.
0.T .
ST.
WED.
O.T
ST.
THUR.
O.T
ST.
FRI.
O.T
ST.
SAT.
O.T
ST.
O.T .
ST.
O.T.
Daily Initials
MATERIALS
DATES AND QUANTITIES
TOTAL QUANTITIES
DESCRIPTION OF ITEMS SUN.
MON.
TUES.
Page 1 of 2
WED.
THUR.
FRI.
SAT.
QTY.
UNITS
EQUIPMENT
DATES AND HOURS TOTAL HOURS
Description SUN
MON
TUES
WED
THUR
FRI
Sat
Daily Initials It is hereby agreed that labor and equipment hours and materials used during the week ending correctly shown above.
Contractor/Utility Company's Authorized Representative
Resident Engineer's Authorized Representative
Company or UDOT Comments:
Page 2 of 2
are
C-107 (10/12)
AUTHORIZATION TO PROCEED WITH EXTRA WORK OR REVISION OF CONTRACT
(A CHANGE ORDER MUST BE COMPLETED WITHIN 30 DAYS OF DATE OF SIGNATURES) Project No:
Location:
Contractor:
Type Revision: Change Order
Specification Change
Time Extension
Requested by:
Other
Date:
Nature of and Reason for Proposed Revision (Brief explanation, if additional space is needed, use reverse side)
Estimated
Increase In Cost Decrease
Method of Payment
$
Original Contract Unit Price
Agreed Unit Price
Force Account
The work covered by the Proposed Revision as described above is hereby authorized subject to the conditions marked below: Evaluation of cost data.
Other (brief explanation):
Adequate submittal of written supporting data. Determination of satisfactory time adjustment. Final approval by Approving Authority.
Authorization to Proceed (signatures Required) PROJECT MANAGER Verbal approval
/
/
FHWA/DISTRICT ENGINEER
)
Verbal approval Emergencies) Date:
/
Date:
(For Non-Major Changes or Date:
/
/____
Date:
/
/____
CONTRACTOR /
/_____
REGION DIRECTOR ____________________________________
/
/____
RESIDENT ENGINEER Date:
/
/
/______
Region Directors signature required for work => $100,000.00
C-107 (10/12)
INSTRUCTIONS: Form C107, Authorization to Proceed with Extra Work or Contract Revision, is used for documenting verbal approval for non-major changes and non-major extra work and emergency work. Additionally, whenever a major change is necessary and the time necessary to prepare, submit and obtain approval of a change order will delay the orderly progress of work, the Resident Engineer prepares the Form C107 specifying the extra work to be completed, the reason for the change, and the total estimated cost of performing the work. The Resident Engineer obtains verbal approval for non-major changes and in emergency situations before starting additional work by contacting the Project Manager, District Engineer, FHWA, and Local Governments, when applicable. Note that verbal approval only applies to non-major changes and emergency situations. The Resident Engineer obtains written approval before the start of additional work when a major change is required. The Region Director’s signature is required when additional work is valued at $100,000.00 or more. After Form C107 is completed the Contractor can be authorized to proceed with the work. Complete form C100 (Change Order) within 30 days and attach a copy of the approved C107. Refer to policy and procedure 08B-10 for additional information.
UTAH DEPARTM ENT OF TRANSPORTATI ON
Form C-114 (10/12)
Signature Sheet
PROJECT NO.: LOCATI ON:
EM PLOYEES NAM E
TI TLE
SI GNATURE
I NI TI ALS
Form C-114 (10/12)
I nstructions for C-114 Form C-114: Signature Sheet Use: Prepared by Resident Engineer. This form is required on all projects and is a list of all signatures/initials of personnel that have worked on a specific project. It should be started at the beginning of each project and takes the place of the signature area in the front of the field books.
Form C118 5/17/10
UTAH DEPARTMENT OF TRANSPORTATION CONSTRUCTION OVERRUN FUNDING NEED (COFN)
Project No. Contractor: Date:
Pin No: Auth No.: 5305303C
Contract No. Request No. Estimate No.
Basis for Request of Authorization Covering Overrun in Contract Amount (List all Change Orders\Items Overrunning and Amounts for this request:) CO. Nos: Amount: ItemsOverrunning Amount
Total: 0
Estimated Time Table:
Month
Total Request:
0
DEPARTMENT OF TRANSPORTATION
Resident Engineer Project Funds Availablilty Avail. Needed
ORIGINAL CONTRACT AMOUNT: PREVIOUS COFN's: TOTAL COFN's: (including this one) $ TOTAL Authorized Amount: (Original Contract Amt plus COFN's) $ Percent of Supplemental Authorizations: COMMENTS:
Date
Project Manager
-
Date
Funding Need Acknowledged
0 Program Finance Office
Date
Payment Processed
Comptrollers Office
Processed in Central Construction
Date
Date
Form C-118U 10/7/10
UTAH DEPARTMENT OF TRANSPORTATION UTILITY CONTRACT OVERRUN FUNDING NEED (uCOFN)
Project No. Utility Co: Date:
Pin No: Auth No.:
Agreement No. Request No. Estimate No.
Basis for Request of Authorization Covering Overrun in Contract Amount (List all Change Orders\Items Overrunning and Amounts for this request:) CO. Nos: Amount: ItemsOverrunning Amount 0 Estimated Time Table:
Month
Total: 0
0
Total Request:
0
DEPARTMENT OF TRANSPORTATION
ORIGINAL CONTRACT AMOUNT: PREVIOUS COFN's: TOTAL COFN's: (including this one) TOTAL Authorized Amount: (Original Contract Amt plus COFN's) Percent of Supplemental Authorizations: COMMENTS:
0
Resident Engineer Project Funds Availablilty Avail. Needed
Date
0 Project Manager
0
Date
Funding Need Acknowledged
0 Program Finance Office
Date
Payment Processed
Comptrollers Office
Processed in Central Construction
Date
Date
Utah Department of Transportation Contractor Performance Rating Form Form C-119 (09/11) This Contractor Rating Form (Form C-119) replaces the existing Contactor Performance Report (old Form C-119) and shall be used on all projects. Prepare the rating and submit a signed hardcopy to Central Construction at the completion of a project and at the beginning of the calendar year for those projects that require two or more construction seasons. Intermediate ratings prepared throughout the length of the project are not submitted to the Central Construction. However their use is encouraged as a partnering tool to evaluate the contractor’s performance to date and eliminate any “surprises” when the final rating is prepared. It is recommended that the frequency of intermediate ratings should be established at the pre-construction conference. Answer the 40 questions based on a scale of 0-10, (Non-performance = 0; Performance 100% of the time = 10) (Question 6 is 0-100). Decimals can be used if desired. Use Tab Key to move through rating questions. Do not hit Enter as this will calculate form. N/A option can be used for those questions where the contractor was not required to perform a particular function, as in questions 13 & 14, the submittal or the correction of payrolls. Questions 2, 3, 4, & 5 require responses based on specific material quality issues. An area for comments is provided at the end of each section. Ratings of less than 70% require explanations.
After Filling Out Entire Form Click "Calculate Performance Rating" Below and Print the Generated Page for Signatures. Please fill out the following form Completely (all fields required): Date: IntermediateRating Rating Type of Rating: Intermediate
Project Number: Project Name: Contractor: Resident Engineer:
Quality Control/Workmanship (10% Weighting) 1. Items of work completed prior to full project completion were protected from damage. 2. Issues raised in a dispute resolution analysis in accordance with Specification 01456 that were determined to be caused by the contractor or contractor hired consultatnt lab's personnel or equipment. (Number submitted: 0 = 10; 1-2 = 7; 3-4 = 4; 5 or more = 0) 3. Number of times reject material remains in reject after a materials dispute analysis is submitted in accordance with Specification 01456.
(Number submitted: 0 = 10; 1-2 = 7; 3-4 = 4; 5 or more = 0) 4. Contractor placed base material that was required to be removed and replaced. (Number of lots removed and replaced: 0 = 10; 1-2 = 7; 3-4 = 4; 5 or more = 0) 5. Overall average percent within paving limits for HMA paving on the project in accordance with Specification 02741. If no HMA paving was placed, overall average percent within paving limits for surface course on the project in accordance with Specifications 02744, 02786 and 02787. (Percent within limits: 100 = 10; 95-99 = 9; 91-94 = 8; 85-90 = 7; 81-84 = 5; 75-80 = 4; 71-74 = 2; 61-70 = 1; 60 or less = 0) Quality Control/Workmanship Comments:
Safety (15% Weighting) 6. Safety Rating based on Average Region Safety and Loss Coordinator's audits on Project (0-100) (Enter Average of all safety audits to date in box) Safety Comments:
Work Zone Traffic Control (15% Weighting) 7. Contractor and subcontractors followed the traffic control plan. 8. Traffic Control Maintainer made the minimum day and night inspections. 9. Contractor removed traffic control when no work was in progress. 10. Contractor did not allow parked equipment or private vehicles to create a hazard to the traveling public. 11. Contractor maintained compliance with UDOT standards in all areas of the traffic control operations. 12. Traffic Control Maintainer available when required. Work Zone Traffic Control Comments:
EEO/Labor Compliance (5% Weighting) 13. Contractor submitted payrolls when required. 14. Promptly complied when payroll corrections were requested. 15. Took corrective action when notified of problems found on Labor/EEO interviews. 16. Subcontractors in full compliance were paid promptly. 17. Contractor maintained the project bulletin board. EEO/Labor Compliance Comments:
Environmental Compliance (10% Weighting) 18. Contractor complied with environmental laws and regulations. Environmental Compliance Comments:
Administration/Organization/Supervision (10% Weighting) 19. Contractor resolved delays quickly and efficiently. 20. Contractor provided adequate supervision of subcontractors. 21. Contractor and subcontractor made timely payments for material furnished to the project. 22. Project supervision had a positive impact on the project. 23. Contractor negotiated Change Orders prior to starting work. 24. Contractor provided all submittals to the RE as required by the Standard & Supplemental Specifications in a timely manner. 25. Contractor provided all required Manufacturer's Certificates of Compliance to the RE prior to the materials being incorporated in the the project. Administration/Organization/Supervision Comments:
Partnering (5% Weighting) 26. Contractor’s organization supported partnering concepts. 27. Contractor included subcontractors in the partnering process. 28. Contractor followed the escalation process. 29. Evaluation of partnering was discussed at regular meetings. Partnering Comments:
Schedule (15% Weighting) 30. Contractor submitted Baseline CPM that clearly represented his approach to the project. 31. Contractor submitted monthly updates to the construction schedule. 32. Contractor used construction schedule as a tool to manage the project. 33. Request for extensions of time backed up by valid documentation. 34. Project schedule discussed during the weekly planning meetings. Schedule Comments:
Public Relations (15% Weighting) 35. Contractor addressed public relation concerns of the Engineer in a timely manner. 36. Contractor responsive to the concerns of business owners and residents. 37. Contractor responsive to the traveling public. 38. Contractor updated effected businesses and residents of the work
schedule as per specification. 39. Compensation was reduced for failure to comply with the Public Information Services Specification. 40. Project was maintained in a neat and orderly manner. Public Relations Comments:
COMMENTS:
-- End of Form C-119 --
Form C193 (03/09) (Project Final)
UTILITY FISCAL REVIEW REPORT Project Number: Utility Company:
RESIDENT ENGINEER 1.
Relocation Completion Information:
a. Date Work Started: b. Date Work Completed: c. Date of Verification of Work Completed:
2.
Comparison of Estimate Billing: Estimated
Billing
Difference
a. Labor
$0.00
b. Materials
$0.00
c. Salvage Credits
$0.00
d. Equipment
$0.00
e. R. O. W.
$0.00
f. Overhead
$0.00
g. Engineering
$0.00
h. Miscellaneous
$0.00
i. Other
$0.00 Change Order No.
$0.00
Change Order No.
$0.00
Total Less Company's Share States Share
$0.00
$0.00
$0.00
% %
NOTE: Major Differences Should be Explained:
(use back of form if necessary)
The project records were reviewed and found to be adequate for support of final payment. The Utah Department of Transportation certifies that the work is complete, acceptable, and in accordance with the terms of the agreement. / / Date
Resident Engineer
/
/ Date
District Engineer
SALVAGE CREDIT REPORT FOR UTILITIES AND RAILROADS
Form C193A Revised (8/06)
19 Project No.:
Authority No.:
Location: Name of Utility or Railroad: Agreement No.:
Date of Agreement:
Salvage costs of any material will be deducted from the billings to U.D.O.T. Please fill in the following blanks and return this form with the enclosed bill through the District Engineer to the Construction Division, c/o Contracts, Estimates and Agreements Manager. 1.
If the bill shows no credit due the State, should it have shown such credit? Yes
2.
No
If so, or if credit is shown for such materials, were you notified in writing by the utility or railroad company of the time and place that the required inspection of recovered materials could be made? Yes
3.
No
Did you make such inspection: Yes
No
4.
If not, why?
5.
What is the status of the salvaged material, ie., was it scrapped, junked, sent to storage, etc.:
6.
It was determined by the above listed utility or railroad that the materials removed had no salvage value.
(Complete Item No. 6 if applicable. Utility or Railroad must sign if applicable.)
/ Date
Utility or Railroad Representative Date
Resident Engineer
Note: If you need more room, please continue on the back of this sheet.
Date
/
District Engineer
Form C300 Rev. 2/2011
FUEL COST ADJUSTMENT Project No.: Partial Estimate No.: Bid Opening Date: Project Starting Date: Inclusive Dates of Estimate Period: Contract Completion/Expired Date: Base Price for Fuel (BPf): Estimate Price for Fuel (EPf): Is EPF/BPF>1.15 Is (Epf / BPf)<0.85 Item of Work
01282 Part 1.15 Adjustment Formula (Epf / BPf) > 1.15: FCA = [[(EPf - BPf) - 0.05 BPf] Q (FF)]/42 (Epf / BPf) < 0.85: FCA = [[(EPf - BPf) + 0.05 BPf] Q (FF)]/42 Weekly Values for EPf Calculation (West Texas Intermediate) 3rd Monday Prior 2nd Monday Prior 1st Monday Prior
$0.00 #DIV/0! #DIV/0! Fuel Factor (FF) 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000
1st Monday of current Month
#DIV/0! #DIV/0! Quantity of Acceptable Work Fuel Cost Adjustment (Q) (FCA) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL:
Computed by: Checked by:
$0.00 $0.00 $0.00 $0.00
$0.00
Form C302 Rev. 5/09
Asphalt Cost Adjustment
Data Entry
Project No.: Partial Estimate No.: Bid Opening Date: Project Starting Date: Beginning Date of Estimate: Ending Date of Estimate: Contract Completion/Expired Date:
STP-0030(20)99 8 04/26/09 05/08/09 05/20/09 05/26/09
Base Price for Asphalt (BPa): Index on date of bid.
$508.00
www.udot.utah.gov/main/f?p=100:pg:11103261715683285000:::1:T,V:1726
Monthly Estimate Price for Asphalt Month / Year Estimate Price for Asphalt (EPa): Change from Contract Base Price:
May-08 $510.00 $2.00
01282M Part 1.13 Adjustment Formula EPa > (BPa * 115%): ACA = [EPa - (Bpa * 115%)] T EPa < (BPa * 85%): ACA = [EPa - (Bpa * 85%)] T
Adjustment Value $0.00 $0.00
Doesn't Apply Doesn't Apply
A positive value is a credit to the contractor A negative value is a credit to the agency
Quantity in Tons of Percentage of Asphalt in Quantity in Tons of the Asphalt Based Asphalt Based Material (Target Asphalt Used Materials Used (T) or) (Measured (T) Average) 5000.00 4.50% 225.00 1000.00 4.35% 43.50 50.00 100.00% 50.00 20.00 65.00% 13.00 300.00 100.00% 300.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 65.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00
Item of Work
#33 HMA - 3/4 Inch #34 HMA - 3/8 Inch (Lane Leveling) #35 Liquid Asphalt MC-70 or MC-250 #41 Emulsified Asphalt LMCRS-2 #43 PG Asphalt 64-34 (OGSC)
TOTAL: Computed by: Checked by:
Asphalt Cost Adjustment (ACA)
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00
R5 11/12
UTAH DEPARTMENT OF TRANSPORTATION TRANSFER OF MATERIAL & EQUIPMENT
FROM TO
(Div/Region):
(Div/Region):
QUANTITY
LOCATION: LOCATION:
DESCRIPTION
CONDITION
RELEASE BY:
RECEIVED BY:
SIGNATURE:
SIGNATURE:
DATE:
DATE:
Construction Inspection Guide
Civil Rights Forms (Federal aid Projects)
C â&#x20AC;&#x201C;130 OJT Rev. 12/12
TRAINING COMMITMENT FORM (This form replaces the required Training Letter of Commitment and is to be completed and submitted to the UDOT Resident Engineer before or at the preconstruction meeting for the project.)
Date: Project #
Location
Company Address City Craft/Classification
Signature
State
ZIP Training Program
Title
Phone # Trainees
Starting Date
Date
Approx # Hrs
Form C-131 (03/12)
EQUAL EMPLOYMENT OPPORTUNITY BULLETIN BOARD PROJECT REVIEW REVIEW DATE: INSPECTED BY: PROJECT NO.: PROJECT LOCATION: PROJECT ENGINEER: CONTRACTOR:
A.
Bulletin Board:
Y = Yes
N = No
Is bulletin board accessible to all employees on a 24 hour basis? Is the bulletin board located in an area where employees generally congregate? Is it maintained properly, contents easy to read, cover of board is unlocked, easy to open? B.
Posters Required: (Federal Aid)
_____ _____ C.
Form FHWA 1022 - Notice Poster. Form FHWA 1495 - Important Wage Rate Information. Form FHWA 1495A - Importante informacion sobre esclas De Salarios Proyecto (DEL SISTEMA) Federal. Form EEOC-P/E-1 - English Equal Employment Opportunity is "The Law". Form EEOC-P/5-1 - La Iquadad De Oportunidades De Employe Es La Lay. Form WH 1321 - Notice to all Employees Working on Federal or Federally Financed Construction Projects. Form WH 1088 - Your Rights - Federal Minimum Wage. Form OSHA 3165 - Job Safety and Health Protection. Form OSHA 3167 - Trabajo Seqero y Saludable. Form WH 1420 - Your Rights under the family and Medical Leave Act of 1993. Form WH 1420A - Sus Derechos bajo La Ley de Ausencia Familiar y Médica de 1993. Form WH 1462 - Notice: Employee Polygraph Protection Act. Form WH 1462A - Aviso: Ley Para La Protección del Empleadocontra la Prueba de Polígrafo. Non-Discrimination Title VI Poster Cartel Titulo VI No-Discriminacion (Spanish Non-Discrimination Title VI Poster)
Additional Notices Required: (Federal Aid) Emergency phone numbers. Wage Rates (found in the Contract Proposal) and 1444 Conformance Requests. Name, address and phone number of Company and Project E.E.O. Officers.
Name, address and phone number of each subcontractor=s E.E.O. Officer and E.E.O. Policy.
FHWA 1273 - Contractor's and Subcontractor’s Affirmative Action Plan. Notice to encourage present employees to refer minority and female applicants. Contractor's Complaint Procedure (on Company letterhead). Each Subcontractor’s Complaint Procedure (on Company letterhead).
COMMENTS:_________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ PROJECT E.E.0. OFFICER
_______________________________________ REGION CONTRACT SPECIALIST
HARASSMENT, INTIMIDATION, AND COERCION Project No.:
E.E.O. Form C133 (1/96)
Date:
Location: Contractor/Subcontractor:
I certify that on
/
/
, I attended a meeting held by my employer during which the employer's
policy regarding sexual harassment, intimidation, and coercion was discussed and explained. I further certify that I understand this policy, and my rights, and that I have knowledge of the avenues of appeal open to me regarding sexual harassment, intimidation, or coercion complaints. Signed:
UTAH DEPARTMENT OF TRANSPORTATION LABOR & EEO INTERVIEW OF WORKERS Y = YES N = NO N/R = NOT REQUIRED C-136 Rev. 2/06
PROJECT NUMBER
PROJECT NAME
PROJECT ENGINEER
CONTRACTOR
SUBCONTRACTOR
NAME OF EMPLOYEE
MALE
HOURLY RATE OBTAINED IN INTERVIEW:
$
PAYROLL: BASE RATE
NO.
FEMALE
Fringe: IN CASH
TO FUND
QUESTION
1.
Do you have a copy of your benefits plan?
2.
Do you receive your pay check weekly?
3.
Are you being paid the correct wage for the work you are doing?
4.
Have you ever been required to return any of your pay to your employer?
5.
Have you ever had your hours changed on your time card to reduce pay?
6.
Do you know the location of the Contractor=s project bulletin board?
7.
Do you know what information on the bulletin board would benefit you?
8.
Truck Driver/Owner-Operator: Do you own the truck you are driving? (Interviewer, please check registration to see if driver is owner)
9.
How long have you been employed with this company?
10.
INTERVIEWED BY: MINORITY (?)
WAGE DECISION BASE
FRINGE
TRAINEE (?)
DATE OF INTERVIEW:
TRAINEE WAGE
CLASSIFICATION:
BASE
Y/N
a.
Who is the Company EEO Officer?
b.
Have you attended a Company meeting where EEO was discussed?
c.
Who conducted the meeting?
d.
What topics were discussed?
e.
Have you attended a Company meeting where harassment, intimidation and coercion were discussed?
When ?
d.
Have you received any other information on the Company=s policy on harassment, intimidation and coercion?
How?
11.
Have you been asked to refer minorities and women for employment?
12.
Have you been informed of available training programs?
13.
Trainees: Have you received a copy of your training program? Are you receiving training in the craft in which you are registered?
b.
Are you satisfied with the training you are receiving?
c.
Have you had construction experience prior to being registered in your present training program?
d.
What was the trainee doing at the time of the interview?
14.
Are you a student or a teacher?
15.
Do you have any complaints?
16.
To whom do you direct your complaints?
INTERVIEWER REMARKS: (If additional space is needed, use reverse side of page).
FRINGE
COMMENTS
Are you familiar with the Equal Employment Program and the EEO Policy?
a.
REGION
When ?
What type?
Form C-136 Utah Department of Transportation LABOR AND EEO INTERVIEW OF WORKERS Form C-136 is to be completed each time an interview is taken with an employee of the contractor or subcontractors on a Federal-aid project. UDOT Resident Engineer or appropriate designee should conduct interviews during the second and fourth week the Prime Contractor and/or each Subcontractor is on the project site. As each new subcontractor begins working on the site, interview those employees. Authorized interviewer selects random number of Contractor or subcontractor employees representative of each craft on the project site. When possible, interview at least one Caucasian, one minority and one female from each contractor and subcontractor. If contractor’s work force is comprised of eight persons or less, interview all employees. If no turnover in contractor personnel, follow-up spot check interviews once every 45 days. When each interview has been accomplished C-136 is compared to payroll for the same time frame. All persons interviewed should be on that payroll and should have been paid for work performed (classification and time) during week interviewed. If employees on C-136 are not on payroll for corresponding week: contractor is notified and requested to submit supplemental payroll. Original C-136 is retained in the project office files unless there is a problem the project office nor the Region Contract’s Specialist (RCS) can resolve. If there are such problems, RCS checks for completeness and then initials and sends to Civil Rights office with explanation and history of attempts to resolve. As security measure: Develop a system in the project office to prevent unauthorized disclosure from happening; Place interviews in a file, out of sight, as soon as possible; Only to be reviewed by those who are responsible for processing them. It is against federal regulation for us, as UDOT employees, regardless of our position with the State, to disclose to anyone, other than those involved in the processing of this confidential material, the information acquired during an interview of a Contractor's or Subcontractor's employee without the prior written consent of that employee. (29CFR Part 5.6 (a)(5); USCA Title 5, 552a)
Instructions for completing Form C-136 Top section: Complete as each block indicates. Please write clearly. Wage blocks: Ask interviewee what their hourly wage is. Write what they tell you in the “Hourly Rate Obtained in Interview” block. If they aren’t exactly sure, also include a plus/minus symbol. Payroll block: Write in the wage shown on the payroll for that week for that employee. If fringe amount is not paid to an approved plan, it is considered “cash”. Wage Decision block: Check the corresponding wage decision for that project and write in the required wage for that employee’s classification. Trainee Wage block: If employee being interviewed is an Apprentice or Trainee, write what the correct wage should be for the level (%) that employee has attained. This information should be on the certification submitted by the contractor for the Apprentice or Trainee. If not, ask the contractor for it. #1 Ask the employee if they have insurances or a pension provided by their employer. If they say “yes”, ask them question #1. If they say “no”, write N/R in the “Y/N” column. #2 through #7 – ask the question indicated and write “Y” or “N” in that column and if there is additional information, write it in the “Comments” column corresponding with the question asked. #8 If interviewing an owner/operator truck driver (not just a regular truck driver), ask question #8. Write answer in Y/N column. Ask for the registration of the truck to see if driver is the owner. If the registration does not match the name of the driver, write the “owner” information from the registration in the comments space. #9 through #10e - ask the question indicated and write “Y” or “N” in that column and if there is additional information, write it in the “Comments” column corresponding with the question asked. #10d
This question means if they have been given any written information – anything more than just being told about HIC in a meeting.
#11 through #12 - ask the question indicated and write “Y” or “N” in that column and if there is additional information, write it in the “Comments” column corresponding with the question asked. #13 Ask the employee if they are an Apprentice or Trainee. Trainee, in this case, means both Apprentice and Trainee. If the employee answers “yes”, continue with question #13, a through d. If the employee answers “no”, write “N/R” in the N/Y column and proceed to #14. #14 through #16 - ask the question indicated and write “Y” or “N” in that column and if there is additional information, write it in the “Comments” column corresponding with the question asked. Interviewer Remarks: If you have noticed or heard anything pertinent to this interview, or if interviewer has an opinion about the interview, write about it in this section.
Form C‐138 Rev. 12/12
CIVIL RIGHTS FINAL PAYMENT CHECKLIST Project/PIN Number: _________________________________
Date: _______________________
Prime Contractor: ____________________________________
Checked By: _______________________ Region
Central
Region
Checked By: _______________________ Central
Verify DBE Goal Verify DBE goal ‐ Subsystems, Project Admin, Project Detail. If DBE goal is 0, there is no need to verify. Commitment & participation ‐ get from C‐128 report. % DBE Goal = Commitment = % Participation = % Print Project Details & Management screens ‐ Subsystems, Project Admin & attach to this checklist. DBE Item Payment Analysis ‐ Subsystems, Civil Rights, Reports. "+/‐" amount must be 0 or positive to show the commitment has been met, ok if within 10% of the commitment item amount. Must meet project goal. If commmited item was not used due to change in scope, must have Change Order. Print DBE Item Payment Analysis & attach to this checklist. If there are negative amounts, then commitments are not fully met. Compare to Subsystems, Project Accounting, Amount Overrun: Green = underrun (no way of filling commitment). Must have a change order to bring the commitment in line with the participation. If there are negative amounts and Project Accounting, Amount Overrun is Red = overrun, then check Change Orders ‐ Subsystems, Project Admin, Data Entry, Change Orders. Must do a Change Order if committed items have been eliminated. If the prime commits to a DBE, scope didn’t change and the DBE didn’t perform the work or was paid under 10% of the committed amount (due to changes made by the prime), have the DBE and the prime sign a “Hold Harmless Agreement”. Must have a change order to adjust the commitment. The Hold Harmless Agreement can be found at:
http://www.udot.utah.gov/go/civilrightsforms
Contact Region if missing payments. Comments:
Verify OJT Goal Verify OJT Goal ‐ Subsys, Civil Rights, Goals – Proj DBE/OJT, click on OJT tab. If 0 hours, no need to verify. OJT Goal =
hours
Compare goal with training hours worked ‐ Subsys, Civil Rights, Reports, On the Job Trainee Proj Hours Worked. Apprentice Trainee hours worked = hours (should be ≥ OJT goal) If goal not met, compare hours to OJT100 form to calculate liquidated damages. Provide OJT100 form with final packet. Compare goal with the Project Acc scrn ‐ PDBS, Subsys, Proj Acc, Equal Opp. Training item. (should be = OJT hours worked) Equal Opportunity Training, EOT = hours If hours worked more than doubles the goal, then RE to cut payment off at double the goal. Obtain copy of reimbursement affidavits from contractor verifying the Training Agencies have been paid. Region to send copy with final packet. If Project No. doesn't show up on “On The Job Trainee Project Hours Worked” it’s become inactive on this screen. 2008 & prior – program not implement to track hours.
Comments:
Central
Region
Verify Subcontractor Payments Verify Subcontract Payments ‐ Subsystems, Civil Rights, Subcontractor Payment Entries. Click on each subcontractor and click on retrieve. Make sure all subcontractors have payments. Check sub payments vs. C115 for full payment, enter into tracking spreadsheet. If a sub has no payments: Tier 2, 3, 4, etc. subcontractor payments most likely will not be entered. For tiers check Subsystems, Proj Admin, Data Entry, Subcontracts. Also look at change orders for reasons why. When missing subcontractor payments, contact the Region. Prompt Payment: Dates highlighted in red means that the subcontractor payment was not entered within 10 days (old projects) or 30 days (2012 projects) from when the contractor was paid. Project office can’t pay $250.00 incentive if not entered within 10 days (no incentive for 2012 projects) . They are out of compliance with prompt payment. Verify that each subcontractor has a C‐115 completed ‐ Subsystems, Proj Admin, Data Entry, Subcontracts.
Comments:
Verify Certified Payroll Verify Payroll ‐ Subsystems, Certified Payroll. Click on each contractor to make sure they have payrolls in the system. Not all payrolls will have names listed, so check payrolls until one does. Most trucking companies, suppliers, professional services, engineering firms & surveyors do not require certified payrolls. Check C‐115 for these types of work. If payroll dates show up, but no employees are listed, check under Exceptions for salary employees. Check the Exceptions, they must include employee position and reason for exception (i.e. salaried foreman). If missing payrolls, verify Award Date = ___________ ‐ PDBS, Subsystems, Project Admin. If the award date is November 2009 or before, it will have paper payrolls and will not be in the Certified Payroll program. Also, if missing payrolls, look at change orders ‐ Subsystems, Project Admin, Data Entry, Change Orders for why. If there was a payment made to the sub in the Subcontractor Payments screen but no payroll, contact the Region to enter the payrolls. If Davis Bacon Wages are not applicable, there will not be any payrolls. Employee Exceptions ‐ Certified Payroll, Reports. Check if corrections/adjustments were made in Cert. Payroll, Payroll Preview. If so, status should be changed to Accepted. If status is Accepted without adjustments, contact Region to have contractor fix it. 1391 Report ‐ Certified Payroll, Reports, 1391 Salary Entry. Check that each contractor has entered info monthly for ARRA projects and for the month of July for all other projects. Pick project, company name, and reporting month year. Check Project Act Report ‐ Cert Payroll, Reports for months worked. Form 1444 ‐ Certified Payroll, Form 1444. Check that each contractor does not have outstanding 1444 requests. If one shows up then check to make sure Civil Rights and Department of Labor (DOL) have approved it. If the DOL rejects a request and provides a new rate, obtain documentation from the contractor that they paid the difference in rates. Comments:
File this Checklist with attached documents in Civil Rights drawers (in Judy’s office).
Training Hours Reimbursement Affidavit
Project Number _________________________
Training Goal ____________hrs
Prime Construction Company ____________________________________ _______________________ Construction Company has reimbursed the following Training Agency(s):
(Prime Construction Company)
___________________________
$______________________
____________________
_________
___________________________
$______________________
____________________
_________
___________________________
$______________________
____________________
_________
(Training Agency)
(Training Agency)
(Training Agency)
(Paid in the amount of)
(Paid in the amount of)
(Paid in the amount of)
(Training Agency Signature)
(Training Agency Signature)
(Training Agency Signature)
Total Training hours paid ____________ Sub-Contractors paid for Training hours: ________________________________
$_________________
________________________________
$_________________
________________________________
$_________________
________________________________
$_________________
________________________________
$_________________
________________________________
$_________________
(Sub-Contractor)
(Sub-Contractor)
(Sub-Contractor)
(Sub-Contractor)
(Sub-Contractor)
(Sub-Contractor)
(Paid in the amount of)
(Paid in the amount of)
(Paid in the amount of)
(Paid in the amount of)
(Paid in the amount of)
(Paid in the amount of)
Prime Contractor Signature _____________________________________
Date ______________
(Date)
(Date)
(Date)
Training Hours Reimbursement Affidavit
Project Number _________________________
Training Goal ____________hrs
Sub-Contractor Construction Company ____________________________________ _______________________ Construction Company has reimbursed the following Training Agency(s):
(Sub-Contractor Construction Company)
___________________________
$______________________
____________________
_________
___________________________
$______________________
____________________
_________
___________________________
$______________________
____________________
_________
(Training Agency)
(Training Agency)
(Training Agency)
(Paid in the amount of)
(Paid in the amount of)
(Paid in the amount of)
(Training Agency Signature)
(Training Agency Signature)
(Training Agency Signature)
Total Training hours paid ____________
Sub-Contractor Signature _____________________________________
Date ______________
(Date)
(Date)
(Date)
Project No:
Form C-141 (Rev. 4/26/06)
UDOT DBE COMMERCIALLY USEFUL FUNCTION (CUF) PROJECT SITE REVIEW Reviewer: Region: Review Date:
Project Name: Prime Contractor: DBE Subcontractor: DBE Foreman/Supt: Work Item: (Continue on back of form)
DBE Start Date: Work Item Description
Circle the correct answer below: Exclusively employed by DBE? Yes Shown on any other firm’s payroll? Yes Directly reports to:
DBE Completion Date:
Approximate % Complete as of this date
Subcontracted Dollar Amount
REGARDING DBE’S FOREMAN/SUPT. No No
Shown on the DBE payroll? If yes, whose?
Yes
No
REGARDING DBE’S EMPLOYEES
Are DBE’s employees shown on any other contractor’s payrolls? If yes, whose? Do the DBE’s employees receive work assignments from DBE Foreman/Supt? REGARDING DBE’S EQUIPMENT
Yes
No
Yes
No
Does the equipment have the DBE’s name or logo? Yes No If another firm’s name or logo is shown, identify: ____________________________________________________________ Does the equipment belong to the DBE? Yes No If leased or rented, is there a copy of the lease or rental agreement in project file? Yes No REGARDING DBE’S WORK PERFORMANCE Has any other contractor performed work that was to be performed by the DBE? If yes, identify the contractor who performed the work:
Yes
No
What work items did the identified contractor perform? (If more than two, write on back of form) ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Were these items on the DBE’s subcontract? Yes No Has the DBE owner been present on the job site? Yes No Does the DBE appear to have control over their work and employees? Yes No Comments: (any comments pertaining to the performance or conduct of the DBE company) Has UDOT Civil Rights been notified of any problem(s) identified in this report? If no, explain why:
Yes
No
C-141 Instructions: The CUF Form C-141 must be completed at least once for each DBE working on a UDOT Federal Highway Construction Contract, during the life of the contract. Please refer to the following information for guidance in completing the CUF. COMMERCIALLY USEFUL FUNCTION (CUF) – FHWA 49CFR26.55 DBE CONTRACTOR MUST PERFORM A CUF TO SATISFY THE CONTRACT GOAL) MANAGE: • Manage the work themselves. o Schedule work operations, order equipment and materials, hire and fire employees, including supervisory employees. SUPERVISE: • Supervise daily operations o Can use a skilled Superintendent employed by the DBE. PERFORM: • Perform the work stated in the contract with their own equipment. o AS STATED IN THE DBE SPECIAL PROVISIONS: Regular Equipment is owned or leased and operated on a long term agreement and not on an ad hoc or contract by contract agreement. a. The equipment would be used by the DBE firm on any other subcontract with any other contractor. b. The equipment would be owned by the DBE firm. Or The equipment would be leased/rented from traditional equipment lease/rental sources. c. The DBE firm would have a rental/lease agreement for any rented or leased equipment. d. The equipment cannot belong to: (1.) Prime Contractor (2.) Another subcontractor on the present project. (3.) Supplier of materials being installed by the DBE firm. e. The equipment cannot come from another contractor fully operated. • Perform the work with their own employees. o AS STATED IN THE DBE SPECIAL PROVISIONS Regular Employee is a person who: a. Would be working for the DBE firm on any other subcontract with any other contractor. b. Is a permanent employee of the DBE firm, Or Has been recruited through the traditional recruitment and/or employment centers. c. Has not recently been employed by the prime contractor on the present project, another subcontractor on the present project, or the renter-lesser of equipment being used on the present project. d. Is not a member of a construction crew, which regularly works for a non-DBE. e. Is not a licensed contractor who is at the time “unemployed” or “between jobs.” • Subcontracting part of the work of the contract. o When a DBE subcontracts part of the work of its contract to another firm, the value of the subcontracted work may be counted toward the DBE goal only if the DBE subcontractor is itself a DBE. Work that a DBE subcontracts to a non-DBE firm does not count toward DBE goals. • Trucks/Equipment must display name of DBE firm o Printed name or logo o Leased or rented equipment: A copy of the lease/rental must be submitted to the project office and put in the project file. • Supplier - Regular Dealer A regular dealer is a firm that owns, operates, or maintains a store, warehouse, or other establishment in which the materials, supplies, articles or equipment of the general character described by the specifications and required under the contract are bought, kept in stock, and regularly sold or leased to the public in the usual course of business. 60% of the cost of materials, supplies and delivery counts toward the DBE goal. • Supplier – Service Provider o Only the fees or commissions charged by the DBE Service Provider count toward DBE goals. The Cost of the materials or supplies are not counted toward the DBE goal. TRUCKING CLARIFICATION (S) The DEPARTMENT shall use the following factors (as stated in the Special Provisions) in determining whether a DBE trucking company is performing a commercially useful function: a. b. c. d.
The DBE must itself own and operate at least one fully licensed, insured, and operational truck used on the contract. The DBE must be responsible for the management and supervision of the entire trucking arrangement for the purpose of meeting DBE goals. The DBE receives credit for the total value of the transportation services it provides on the contract using trucks its owns, insures, and operates using drivers it employs. The DBE may lease trucks from another DBE firm, including an owner-operator who is certified as a DBE. The DBE who leases trucks from another DBE receives credit for the total value of the transportation services the lessee DBE provides on the contract. *See below for payroll reporting.
e.
The DBE who leases trucks from a non-DBE is entitled to credit for the total value of the transportation services provided by non-DBE lessees not to exceed the value of transportation services provided by DBE-owned trucks on the contract. Additional participation by non-DBE lessees receives credit only for the fee or commission it receives as a result of the lease arrangement. Example: DBE Firm X uses two of its own trucks on a contract. It leases two trucks from DBE Firm Y and six trucks from nonDBE Firm Z. DBE credit would be awarded for the total value of transportation services provided by Firm X and Firm Y, and may also be awarded for the total value of transportation services provided by four of the six trucks provided by Firm Z. In all, full credit would be allowed for the participation of eight trucks. With respect to the other two trucks provided by Firm Z, DBE credit could be awarded only for the fees or commissions pertaining to those trucks Firm X receives as a result of the lease with Firm Z.
For purposes of this paragraph (d), a lease must indicate that the DBE has exclusive use of and control over the truck. This does not preclude the leased truck from working for others during the term of the lease with the consent of the DBE, so long as the lease gives the DBE absolute priority for use of the leased truck.
CHECK APPROPRIATE BOX
□SERVICE CONTRACT
REQUEST FOR AUTHORIZATION OF ADDITIONAL CLASSIFICATION AND RATE
□CONSTRUCTION CONTRACT NOTE: THE CONTRACTOR SHALL COMPLETE ITEMS 3 THROUGH 16 AND SUBMIT THE REQUEST, IN QUADRUPLICATE, TO THE CONTRACTING OFFICER 1. ADMINISTRATOR, Employment Standards Administration WAGE AND HOUR DIVISION U.S. DEPARTMENT OF LABOR WASHINGTON, D.C. 20210
2. FROM: (REPORTING OFFICE)
3. CONTRACTOR
4. DATE OF REQUEST
5. CONTRACT NUMBER
6. DATE BID OPENED (SEALED BIDDING)
7. DATE OF AWARD
8. DATE CONTRACT WORK STARTED
9. DATE OPTION EXERCISED (IF APPLICABLE)(SCA ONLY)
10. SUBCONTRACTOR (IF ANY)
11. PROJECT AND DESCRIPTION OF WORK (ATTACH ADDITIONAL SHEET IF NEEDED)
12. LOCATION (CITY, COUNTY AND STATE)
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE INDICATED CLASSIFICATION(S) INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION NUMBER
NOT
DATED
a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE PROPOSED CLASSIFICATIONS (SCA ONLY)
FOR
b. WAGE RATE(S)
c. FRINGE BENEFITS PAYMENTS
(Use reverse or attach additional sheets, if necessary)
14. SIGNATURE AND TITLE OF SUBCONTRACTOR REPRESENTATIVE (IF ANY)
15. SIGNATURE AND TITLE OF PRIME CONTRACTOR REPRESENTATIVE
16. SIGNATURE OF EMPLOYEE OR REPRESENTATIVE
TITLE
CHECK APPROPRIATE BOX - REFERENCE BLOCK 13
□AGREE □ DISAGREE
TO BE COMPLETED BY CONTRACTING OFFICER (CHECK AS APPROPRIATE - SEE FAR 22.1019 (SCA) OR FAR 22.406-3 (DBA)
□ □
THE INTERESTED PARTIES AGREE AND THE CONTRACTING OFFICER RECOMMENDS APPROVAL BY THE WAGE AND HOUR DIVISION. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED. THE INTERESTED PARTIES CANNOT AGREE ON THE PROPOSED CLASSIFICATION AND WAGE RATE. A DETERMINATION OF THE QUESTION BY THE WAGE AND HOUR DIVISION IS THEREFORE REQUESTED. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED. (Send copies 1, 2, and 3 to Department of Labor)
SIGNATURE OF CONTRACTING OFFICER OR REPRESENTATIVE
NSN 7540-01-268-0631
TITLE AND COMMERCIAL TELEPHONE NO
DATE SUBMITTED
STANDARD FORM 1444 (10-03) Prescribed by GSA FAR (48 CFR) 53.222(9) 1444-101
REQUEST FOR AUTHORIZATION OF ADDITIONAL CLASSIFICATION AND RATE
SAMPLE
CHECK APPROPRIATE BOX
□ SERVICE CONTRACT □ CONSTRUCTION CONTRACT
NOTE: THE CONTRACTOR SHALL COMPLETE ITEMS 3 THROUGH 16 AND SUBMIT THE REQUEST, IN QUADRUPLICATE, TO THE CONTRACTING OFFICER
TO BE COMPLETED BY CONTRACTING AGENCY - (OWNER) OF PROJECT (UDOT)
1. ADMINISTRATOR, Employment Standards Administration WAGE AND HOUR DIVISION U.S. DEPARTMENT OF LABOR WASHINGTON, D.C. 20210
3. CONTRACTOR
2. FROM: (REPORTING OFFICE)
PRIME CONTRACTOR NAME
5. CONTRACT NUMBER
6. DATE BID OPENED (SEALED BIDDING)
PROJECT NUMBER
10. SUBCONTRACTOR (IF ANY)
4. DATE OF REQUEST 7. DATE OF AWARD
8. DATE CONTRACT WORK STARTED
9. DATE OPTION EXERCISED (IF APPLICABLE)(SCA ONLY)
N/A
COMPLETE ONLY IF THERE IS A SUBCONTRACTOR REQUESTING THE RATE
11. PROJECT AND DESCRIPTION OF WORK (ATTACH ADDITIONAL SHEET IF NEEDED)
(Information found on “Notice to Contractors” page in bid document) 12. LOCATION (CITY, COUNTY AND STATE)
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE INDICATED CLASSIFICATION(S) NOT INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION NUMBER
GENERAL DECISION # - TOP OF WAGE RATE DECISION IN CONTRACT
DATED
a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS (SCA ONLY)
EXAMPLE:
DATE OF LAST MODIFICATION OF THAT DECISION b. WAGE RATE(S)
c. FRINGE BENEFITS PAYMENTS
CERTIFIED TRAFFIC CONTROLLER
$ 16.55
$ 4.34
CEMENT MASON
$ 15.45
$ 4.30
(Use reverse or attach additional sheets, if necessary)
14. SIGNATURE AND TITLE OF SUBCONTRACTOR REPRESENTATIVE (IF ANY)
15. SIGNATURE AND TITLE OF PRIME CONTRACTOR REPRESENTATIVE
ONLY IF SUBCONTRACTOR IS MAKING REQUEST
PRIME MUST ALWAYS SIGN
16. SIGNATURE OF EMPLOYEE OR REPRESENTATIVE
TITLE
or write none selected yet TO BE COMPLETED BY CONTRACTING OFFICER
CHECK APPROPRIATE BOX - REFERENCE BLOCK 13
AGREE
DISAGREE
(CHECK AS APPROPRIATE - SEE FAR 22.1019 (SCA) OR FAR 22.406-3 (DBA)
THE INTERESTED PARTIES AGREE AND THE CONTRACTING OFFICER RECOMMENDS APPROVAL BY THE WAGE AND HOUR DIVISION. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED. COMPLETED IN UDOT CENTRAL OFFICE THE INTERESTED PARTIES CANNOT AGREE ON THE PROPOSED CLASSIFICATION AND WAGE RATE. A DETERMINATION OF THE QUESTION BY THE WAGE AND HOUR DIVISION IS THEREFORE REQUESTED. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED. (Send copies 1, 2, and 3 to Department of Labor)
SIGNATURE OF CONTRACTING OFFICER OR REPRESENTATIVE
TITLE AND COMMERCIAL TELEPHONE NO
DATE SUBMITTED
LABOR SPECIALIST - UDOT NSN 7540-01-268-0631
STANDARD FORM 1444 (10-87) Prescribed by GSA FAR (48 CFR) 53.222(9) 1444-101
PROJECT EMPLOYMENT DATA EEO AND LABOR COMPLIANCE REVIEW Contract Start Date: Contract Complete Date: Contract Amount: Project #: Location: Total Workforce: Total Racial Minority African American Hispanic American American Indian Asian American Number Work Hrs. Number Work Hrs. Number Work Hrs. Number Work Hrs. Number Work Hrs. Number Work Hrs. M F M F M F M F M F M F M F M F M F M F M F M F
Form C-257
(08/05)
Review Period: Contractor: Job Category:
Official(s) Supervisors Foremen/Women Administrative Equipment Operator Mechanics/Oilers Truck Drivers Ironworkers Carpenter/Piledrivers Cement Mason/Finisher Electricians Plumber/Pipefitter Painter Laborer-Semi/Unskilled TOTAL TOTAL ALL EMPS TOTAL ALL HOURS TOTAL MINORITIES TOTAL MINORITY HRS. Total Female % #DIV/0! Total Minority % #DIV/0! *County Avg % Minority & Female Availability *To be entered by UDOT
#DIV/0!
% Hrs.
#DIV/0!
% Hrs. M
F
White Number Work Hrs. M F M F
PAY ROL L FORM (FOR CONTRACTOR’S OPTIONAL USE)
NAME OF CONTRACTOR OR SUBCONTRACTOR
ADDRESS
PAYROLL NO.
PROJECT NAME AND LOCATION
# Depen. (2)
(1) NAM E, ADDRESS, AND SOCI AL SECURI TY NO. OF EM PLOYEE
WEEK ENDI NG: S
(3) WORK CLASSI FI CATI ON
(4) DAY AND DATE T W T
F
(4) HOURS WORKED EACH DAY OT
ST
OT ST OT ST OT ST OT ST OT ST OT ST OT ST OT
WH-347 (Rev. 10/06)
M
S
(5) TOTAL HOURS
(6) RATE OF PAY
(7) GROSS AM OUNT EARNED
FI CA
PROJECT NUMBER
WI THHOLDI NG TAX
(8) DEDUCTI ONS STATE MEDITAX CARE
OTHER
TOTAL DEDUCT
(9) NET WAGES PAI D FOR WEEK
Date: ____________________ I,______________________________________________________________ (Name & Title of Signatory Party) do hereby state: (1) That I pay or supervise the payment of the persons employed by ____________________________ on the _____________________________; (Contractor or Subcontractor) (Building or Work) that during the payroll period, commencing on the ______ day of ____________, 200_, and ending the ________ day of __________, 200_, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said ___________________________________________________ from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any persons, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Sta. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276(c), and described below: ____________________________________________________________
(4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS [ ] In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above reference payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (If box (a) is checked, complete (d) on C-349) (b) WHERE FRINGE BENEFITS ARE PAID IN CASH [ ] Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) [ ] EXCEPTIONS (If box (a) is checked, complete (d) on C-349) EXCEPTIONS (CRAFT)
EXPLANATION
____________________________________________________________ ____________________________________________________________ (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work being performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
REMARKS
NAME AND TITLE
SIGNATURE
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution. See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code. WH-348 (Rev.10/06)
Form C-349 (8/06)
(d) BENEFIT PROGRAM INFORMATION IN DOLLARS CONTRIBUTED PER HOUR (Must be completed if box (a) on SOC (WH-348) is checked; or if a dollar amount is in “Other” column on payroll. If the payrolls of the contractor clearly show the fringe activity and/or clearly show what the amount is for in the "other" column, then
the C-349 (this page) does not have to be submitted.
PROJECT NUMBER_______________________________WEEK ENDING DATE_____________________ PROGRAM, CLASSIFICATION, TITLE OR INDIVIDUAL EMPLOYEES
HEALTH / WELFARE
VACATION / HOLIDAY
APPRENTICESHIP / TRAINING
PENSION
OTHER INCLUDE TITLE
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
PROGRAM, CLASSIFICATION, TITLE OR INDIVIDUAL EMPLOYEES
HEALTH / WELFARE
VACATION / HOLIDAY
APPRENTICESHIP / TRAINING
PENSION
OTHER INCLUDE TITLE
Jack Sparrow
$
1.65
$
1.73
$
-----
$
2.25
$
1.00 401K
Jenny Wren
$
1.44
$
.78
$
-----
$
2.25
$
.75 401K
John Doe
$
EXAMPLE:
$
$
$
$ 25.00 Child Support
Department of Labor Wage and Hour Division INSTRUCTIONS FOR COMPLETING PAYROLL FORM, WH-347
General: The use of the WH-347 payroll form is not mandatory. This form has been made available for the convenience of contractors and subcontractors required by their Federal or Federally-aided construction-type contracts and subcontracts to submit weekly payrolls. Properly filled out, this form will satisfy the requirements of Regulations, Parts 3 and 5 (29 CFR, Subtitle A), as to payrolls submitted in connection with contracts subject to the Davis-Bacon and related Acts. This form meets needs resulting from the amendment of Davis-Bacon Act to include fringe benefits provisions. Under this amended law, the contractor is required to pay not less than fringe benefits as predetermined by the Department of Labor, in addition to payment of not less than the predetermined rates. The contractor's obligation to pay fringe benefits may be met either by payment of the fringes to the various plans, funds or programs or by making these payments to the employees as cash in lieu of fringes. This payroll provides for the contractor's showing on the face of the payroll all monies to the employees, whether as basic rates or as cash in lieu of fringes and provides for the contractor's representation in the statement of compliance on the rear of the payroll that he is paying to other fringes required by the contract and not paid as cash in lieu of fringes. Detailed instructions concerning the preparation of the payroll follow: Contractor or Subcontractor: Fill in your firm's name and check appropriate box. Address: Fill in your firm's address. Payroll No.: Payrolls are to be numbered consecutively starting with one (1). For Week Ending: Enter date of last day of weekly pay period. Project Location: Write in project location or name as stated in contract. Project No.: Project number of contract must be written on each page of payroll. Column 1 - Name, Address, and Social Security number of Employee: The employee's full name must be shown on each weekly payroll submitted. The employee's address must also be shown on the payroll covering the first week in which the employee works on the project. The address need not be shown on subsequent weekly payrolls unless the address changes. Social Security numbers are to be shown on each payroll. Column 2 - Withholding Exemptions: This column is merely inserted for the employer's convenience and is not a requirement of Regulations, Part 3 and 5. Column 3 - Work Classifications: List classification descriptive of work actually performed by employees. Consult classification in wage determination set forth in contract specifications. If additional classifications are deemed necessary, see Contracting Officer or Agency representative. Employee may be shown as having worked in more than one classification provided accurate breakdown of hours so worked is maintained and shown on submitted payroll by use of separate entries. If hours cannot be segregated accurately highest wage rate for classifications worked must be paid for all hours worked that day. Column 4 â&#x20AC;&#x201C; Day and Date: Enter date of each day of week (S, M, T, W, Th, F, S) on row (i.e. 10, 11, 12, etc.). Column 4 - Hours worked: On all contracts subject to the Contract Work Hours Standard Act enter as overtime hours worked in excess of 40 hours a week. Column 5 - Total: Self-explanatory Column 6 - Rate of Pay, including Fringe Benefits: In straight time box, list actual hourly basic rate paid the employee for straight time worked plus in cash in lieu of fringes paid the employee. When recording the straight time hourly rate, any cash paid in lieu of fringes may be shown separately from the basic rate, thus $3.25/.40. This is of assistance in correctly computing overtime. Record the base on the top section of ST (column 6) and the fringe amount in the bottom section of ST (column 6). In overtime box (OT- column 6) show overtime basic hourly rate paid. Payment of not less than time and one-half the basic or regular rate paid is required for overtime under the Contract Work Hours Standard Act of 1962. In addition to paying no less than the predetermined rate for the classification which the employee works, the contractor shall pay to approved plans, funds or programs or shall pay as cash in lieu of fringes amounts predetermined as fringe benefits in the wage decision made part of the contract. See "FRINGE BENEFITS" below. FRINGE BENEFITS - Contractors who pay all required fringe benefits: A contractor who pays fringe benefits to approved plans, funds, or programs in amounts not less than were determined in the applicable wage decision of the Secretary of labor shall continue to show on the face of the payroll the basic cash hourly rate and overtime rate paid to his employees just as he has always done. Such a contractor shall check paragraph 4(a) of the Statement of Compliance (Form WH-348) to indicate that he is also paying to approved plans, funds or programs not less than the amount predetermined as fringe benefits for each craft. Any exceptions shall be noted in section 4(c). Contractors who pay no fringe benefits: A contractor who pays no fringe benefits shall pay to the employee, and insert in the straight time hourly rate column of the payroll, an amount not less than the predetermined rate for each classification plus the amount of fringe benefits determined for each classification in the applicable wage decision. Inasmuch as it is not necessary to pay time and a half on cash paid in lieu of fringes, the overtime rate shall be not be less than the sum of the basic predetermined rate, plus the half time premium on basic or regular rate, plus the required cash in lieu of fringes at the straight time rate. In addition, the contractor shall
check paragraph 4(b) of the Statement of Compliance (Form WH-348) to indicate that he is paying fringe benefits in cash directly to his employees. Any exceptions shall be noted in Section 4(c). Use of Section 4(c), Exceptions Any contractor who is making payment to approved plans, funds, or programs in amounts less than the wage determination requires is obliged to pay the deficiency directly to the employees as cash in lieu of fringes. Any exceptions to Section 4(a) or 4(b), whichever the contractor may check, shall be entered in section 4(c). Enter in the Exception column the craft, and enter in the Explanation column the hourly amount paid the employee as cash in lieu of fringes and the hourly amount paid to plans, funds, or programs as fringes. The contractor shall pay, and shall show that he is paying to each such employee for all hours (unless otherwise provided by applicable determination) worked on Federal or Federally assisted project an amount not less than the predetermined rate plus cash in lieu of fringes as shown in Section 4(c). The rate paid and amount of cash paid in lieu of fringe benefits per hour should be entered in column 6 on the payroll. See paragraph on "Contractors who pay no fringe benefits" for computation of overtime rate. Column 7 - Gross Amount Earned: Enter gross amount earned on this project. If part of the employees' weekly wage was earned on projects other than the project described on this payroll, enter in column 7 first the amount earned on the Federal or Federally assisted project and then the gross amount earned during the week on all projects, thus $63.00/$120.00. Column 8 - Deductions: Five columns are provided for showing deductions made. Use first 4 columns to show withholdings for taxes and FICA; if any other deductions are made, show those deductions under "Other" column; show actual total under "Total Deductions" column: and in the attachment to the payroll (Form C349) describe the deduction contained in the "Other" column. All deductions must be in accordance with the provisions of the Copeland Act Regulations, 29 CFR, Part 3. If the employee worked on other jobs in addition to this project, show actual deductions from his weekly gross wage, but indicate that deductions are based on his gross wages. Column 9 - Net Wages Paid for Week: Self-explanatory Statement of Compliance Required by Regulations, Parts 3 and 5: While this form need not be notarized, the Statement of Compliance (Form WH-348) is subject to the penalties provided by 18 USV 1001, namely, possible imprisonment of 5 years or $10,000.00 fine or both. Accordingly, the party signing this statement should have knowledge of the facts represented as true. Space has been provided between item (1) and (2) of the Statement of Compliance for describing any deductions made. See paragraph entitled "FRINGE BENEFITS" above for instructions concerning filling out paragraph 4 of the Statement of Compliance. Form C-349 BENEFIT PROGRAM INFORMATION IN DOLLARS CONTRIBUTED PER HOUR (Must be completed if box (a) on Statement of Compliance (WH-348) is checked; or if a dollar amount is in “Other” column on payroll. If the payrolls of the contractor clearly show the fringe activity and/or clearly show what the amount is for in the "other" column, then form C-349 does not have to be submitted. I NSTRUCTI ONS FOR PREPARATI ON OF STATEM ENT OF COM PLI ANCE – WH-348 & C-349 This statement of compliance meets needs resulting from the amendment of the Davis-Bacon Act to include fringe benefits provisions. Under this amended law, the contractor is required to pay fringe benefits as predetermined by the Department of Labor, in addition to payment of the minimum rates. The contractor’s obligation to pay fringe benefits may be met by payment of the fringes to the various plans, funds, or programs or making these payments to the employees as cash in lieu of fringes. The contractor should show on the face of his payroll all monies paid to the employees whether as basic rates or as cash in lieu of fringes. The contractor shall represent in the statement of compliance that he is paying to others fringes required by the contract and not paid as cash in lieu of fringes. Detailed instructions follow: Contractors who pay all required fringe benefits: A contractor who pays fringe benefits to approved plans, funds, or programs in amounts not less than were determined in the applicable wage decision of the Secretary of Labor shall continue to show on the face of his payroll the basic cash hourly rate and overtime rate paid to his employees, just as he has always done. Such a
contractor shall check paragraph 4(a) of the statement to indicate that he is also paying to approved plans, funds or programs not less than the amount predetermined as fringe benefits for each craft. Any exception shall be noted in Section 4(c). A more detailed accounting of the fringes being paid to a plan, fund or program is required. Complete page 2 (C349) of the Statement of Compliance and attach to the statement to be included with each certified payroll. Remember to include the project number and week ending date on the C349. If the payrolls of the contractor clearly show the fringe activity and/or clearly show what the amount is for in the "other" column, then Form C-349 does not have to be submitted. Contractors who pay no fringe benefits: A contractor who pays no fringe benefits shall pay to the employee and insert in the straight time hourly rate column of his payroll an amount not less than the predetermined rate for each classification plus the amount of fringe benefits determined for each classification in the applicable wage decision. Inasmuch as it is not necessary to pay time and a half on cash paid in lieu of fringes, the overtime rate shall be not less than the sum of the basic predetermined rate, plus the half time premium on the basic or regular rate plus the required cash in lieu of fringes at the straight time rate. To simplify computation of overtime, it is suggested that the straight time basic rate and cash in lieu of fringes be separately stated in the hourly rate column, thus $3.25/.40. In addition, the contractor shall check paragraph 4(b) of the statement to indicate that he is paying fringe benefits in cash directly to his employees. Any exceptions shall be noted in Section 4(c). Use of Section 4©, Exceptions: Any contractor who is making payment to approved plans, funds, or programs in amounts less than the wage determination requires is obliged to pay the deficiency directly to the employees as cash in lieu of fringes. Any exceptions to Section 4(a) or 4(b), whichever the contractor may check, shall be entered in Section 4(c). Enter in the Exception column the craft, and enter in the Explanation column the hourly amount paid the employees as cash in lieu of fringes, and the hourly amount paid to plans, funds, or programs as fringes. U. S. GOVERNMENT PRINTING OFFICE : 1968 0-307-341 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 – Price $1.25 per pad of 100
FEDERAL-AID HIGHWAY CONSTRUCTION CONTRACTORS ANNUAL EEO REPORT 1. MARK APPROPRIATE BLANK(S) _____Contractor _____Subcontractor
2. NAME, STREET ADDRESS OF COMPANY
3. NO OF CONTRACTS
4. DOLLAR AMOUNT OF CONTRACT(S)
5. TYPE OF CONSTRUCTION
6. ESTIMATED PEAK EMPLOYMENT (a) Month in 20__
(b) TOTAL WORKFORCE
This collection of information is required by law and regulation (23 U.S.C. 140a and 23 CFR Part 230 and will be used to identify patterns and trends of employment in the highway construction industry, and to determine the adequacy and impact of the FHWAâ&#x20AC;&#x2122;s contract compliance and on-the-job training programs. Public reporting burden is estimated to average 2 hours per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2125-0019 expiring in March, 2010. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Highway Administration, 1200 New Jersey Ave. SE, Washington DC 20590. .
7. WORKFORCE ON FEDERAL-AID CONSTRUCTION SITE(S) DURING WEEK OF JULY 20_____ Table A JOB CATEGORIES
TOTAL EMPLOYED (Table A)
M
F
WHITE (Not of Hispanic Origin)
M
F
TOTAL R/E MINORITIES (Table A)
M
BLACK (Not of Hispanic Origin)
F
M
F
HISPANIC
M
F
AMERICAN INDIAN or ALASKAN NATIVE
M
F
ASIAN
M
NATIVE HAWAIIAN OR OTHER PACIFIC
F
Table B TWO OR MORE RACES
APPRENTICES
M
F
ON THE JOB TRAINEES
M
OFFICIALS (Managers) SUPERVISORS FOREMEN EQUIPMENT OPERATORS MECHANICS TRUCK DRIVERS IRONWORKERS CARPENTERS CEMENT MASONS ELECTRICIANS PIPEFITTERS, PLUMBERS PAINTERS LABORERS, SEMI-SKILLED LABORERS, UNSKILLED TOTAL
Table C (Table B data by racial status) APPRENTICES ON THE JOB TRAINEES 8. PREPARED BY: (Signature and Title of Contractors Representative)
Form FHWA-1391 (Rev 03-07)
9. DATE
10. REVIEWED BY: (Signature and Title of State Highway Official)
PREVIOUS EDITIONS ARE OBSOLETE
11. DATE
F
Construction Inspection Guide
Inspection Forms
5-DAY ATMS TESTING PRE-NOTIFICATION _____________________________
Date: To: Via FAX #: From: Re: Site:
___________________________________________________________________________
__________________________________________________________________________________
This memo is to serve as notice that the following ATMS component(s) will be tested: CCTV
Traffic Detection Devices
VMS
RWIS
Ramp Meter Signals
Other __________________
The following test(s) will be performed: Cable and Conductor Test Local Field Operations Test 30-Day Burn-In Test The date and time of this test will be as follows (No sooner than 5 business days from the date of this notice): Date: _________________________________ Time: _________________________________ AM
PM
The Department is required to have a witness present to observe the testing. Sincerely, _____________________________ Name
5-Day ATMS Testing Pre-Notification Form Rev. March 23, 2004
_________________________ Date
Page 1 of 1
30 DAY ATMS BURN-IN TEST REPORT Location: ___________________________________ Application: The following ATMS component(s) will be tested:
CCTV
Detection Devices
VMS
RWIS
Ramp Meter Signals Other __________________
Objective: To verify that the installed equipment exhibits stable operation by functioning for 30 days. Prerequisites: 1. Construction at the site must be completed. 2. Local Field Operations tests must be successfully completed. Success Criteria: The site under test successfully operates for 30 consecutive days, excluding failures outside the design-builderâ&#x20AC;&#x2122;s control. Test Initiation
For Contractor installed equipment: Has the Local Field Operations Test been completed? Proceed if Yes, otherwise Stop. Record 30 Day Test Start Date Record 30 Day Test Start Time Authorization to Start 30 Day Test (UDOT Representative Signature) 30 Day Test Period
During the 30 Day Test Period, the owner is encouraged to do any of the following: View video images Pan, tilt, & zoom cameras Adjust camera lens features Operate camera presets Poll device controllers Test Result
Test suspended or terminated. Record date, time, and reason. Successfully completed. Record date & time. The 30-Day Test was successfully completed. (UDOT Representative Signature)
30 Day ATMS Burn-In Test Report Form Rev. March 23, 2004
Page 1 of 1
ATMS CABLE AND CONDUCTOR TEST Site: ______________________________________________ Cable Length _____________ (Feet) Objective: 1. To verify that all cables and conductors are in acceptable condition. Test Equipment: 1. Digital multi-meter with 20,000 ohms per volt or greater input impedance 2. Megger with 250 V, 500 V, and 1000 V range; Insulation resistance range 20 Giga ohms Success Criteria: 1. All wires feature end-to-end continuity 2. There are no short circuits to ground 3. The cables are in good physical condition 4. Conductor resistance is to be calculated with reference to NEC Chapter 9 Table 8 5. Cable slack in junction box shall be 36 inches Test Procedure: Procedure Description
Calculated Measured
Physically inspect all cables. Look for any discontinuities such as opens, shorts, crimps, or defects. (OK if no physical damage, otherwise BAD) Use the audible continuity checker of the digital multi-meter to verify continuity from each connector pin to the corresponding cable end. Note overall result. (OK or BAD) Calculate the resistance for each conductor, NEC Chapter 9 Table 8. Measure the resistance for each conductor. Compare measured to calculated values. OK if not more than 10 ohms per 1000 feet, otherwise BAD Measure the insulation resistance between the conductors and between each conductor, ground, and shielding using the megger. Note result. (OK >500 mega ohms, otherwise Bad) Test Completed by: _____________________ Signature
Date: ____________
_____________________ Print Name ATMS CABLE AND CONDUCTOR TEST FORM REV December 8, 2009
Results Pass/Fail
Witness: ___________________ Signature ___________________ Print Name Page 1 of 1
LOCAL FIELD OPERATIONS TESTING COMPLETION NOTIFICATION _____________________________
Date: To: Via FAX #: From: Re: Site(s):
___________________________________________________________________________
__________________________________________________________________________________ This memo is to serve as notice that the following ATMS component(s) have successfully passed the Local Field Operations Test(s) and are ready to begin Acceptance Testing:
CCTV
Traffic Detection Devices
VMS
RWIS
Ramp Meter Signals
Other __________________
Detailed test results, discrepancies, and resolutions are attached.
Sincerely, ____________________________________ Name
_________________________ Date
ATMS Local Field Operations Testing Completion Notification Rev. March 23, 2004
Page 1 of 1
CLOSED CIRCUIT TELEVISION CAMERA WITH CAMERA LOWERING SYSTEM LOCAL FIELD OPERATIONS TEST Site #:
_________________________________________________________________ Objective:
To demonstrate that the hardware, cables, and connectors operate correctly at the CCTV with Camera Lowering System field site. Definitions:
1. 2.
CCTV - Closed Circuit Television Camera CLS – Camera Lowering System
Prerequisites:
1. 2. 3. 4.
Local construction of CCTV with CLS site has been completed. All CCTV and CLS connecting cabling has been properly installed. Cycle the CLS by lowering and raising the CCTV to the ground, three full cycles. 5-Day pre-notification has been sent to the Owner.
Test Equipment:
1. 2. 3. 4.
Laptop computer Portable NTSC Monitor Current Manufacturer’s Test Program Digital Multi-meter or Scope Meter
Equipment Camera
Make
Model
Serial Number
Cabinet Equipment Test Results
Is all equipment securely bolted in rack? Have all cables and connectors have been installed. Have all terminations for wire and cable been completed according to the NEC, NESC, and latest UDOT Wiring Diagram? Record DC cabinet voltage Record AC cabinet voltage Is AC power available at each outlet? Does GFI button properly trip and reset? Closed Circuit Television (CCTV) Local Field Operations Test Rev. April 23, 2010
Page 1 of 2
Does heater turn on when thermostat is set above ambient temp? Does heater turn off when thermostat is set below ambient temp? Is heater thermostat set to low position? Does fan turn on when thermostat is set below ambient temp? Does fan turn off when thermostat is set above ambient temp? Is fan thermostat set at 95°F (+/- 5°F)? Does cabinet light function with only the front door open? Does cabinet light function with only the rear door open? Does cabinet light go off with both door switches depressed? Does power on/off function work properly? Does the camera have power? Is all equipment securely attached within the cabinet? Is the cabinet fan operating? Note the quality of the video (Reject if snow, lines, or ground loops) Record the peak-to-peak video signal voltage. (Pass if 1V ± 10%) Verify pan Verify tilt Verify zoom Verify focus Verify iris Verify presets Verify low pressure alarm function is on (if applicable) Set camera control address
Test Completed by: _____________________ Signature
Date:
Dept. Representative Witness:
____________
________________________ Signature
_____________________ Print Name
Closed Circuit Television (CCTV) Local Field Operations Test Rev. April 23, 2010
________________________ Print Name
Page 2 of 2
DETECTOR LOOP INDUCTANCE AND RESISTANCE TEST Site: ______________________________________________ Objective: To demonstrate that all loops have the appropriate inductance and resistance. Prerequisites: Loop installation must be complete. Test Equipment: 1. 2.
Loop Analyzer Megger with 250 V, 500 V, and 1000 V range; Insulation resistance range 20 Giga ohms
Success Criteria: 1. 2. 3. 4. 5. 6. 7. 8.
Perform individual Loop resistance test. Must be ≤ the calculated loop resistance by the Designer (Refer to table below) Resistance to ground is no less than 500 Meg-Ohms with a 500 V megger. Inductance is between 65 and 1000 micro-henries. The Q of the loop must be greater than 5 The loop Inductance, Resistance, Q, and Megger test must be performed before connecting the home-run conductors. Perform the Combined Loop Test Form. Disconnect the conductors for the loop being tested. Using the loop analyzer perform the loop (L) inductance, (R) resistance, and Q. With the Megger test the insulation resistance of the loop and home-run cable. Lead-In Slack in junction box shall be 24 inches; Home-Run Slack shall be 24 inches.
Test Results: [ Loop Tested At Junction Box Before Splicing Into Home-Run ] Loop Analyzer
Individual Loop Test Form Loop Dimensions *
Type of Loop Freeway, Ramp, Intersection *
Input File *
Loop Series Resistance *
Loop Test With Lead-In Only At Junction Box
* To be filled out by the Designer Detector Loop Inductance & Resistance Test Form Rev. December 8, 2009
Loop Numbe r
L μH
R Ω
Q >5
Megger
> 500 Meg Ω
1 2 3 4 5 6 7 8 9 10 Page 1 of 2
Pass /Fail
[ Loop Test Before Connecting Home-Run Cable At Junction Box ] Loop Analyzer
Combined Loop Test Form Loop Dimensions *
Type of Loop Freeway, Ramp, Intersection *
Input File *
Loop Series Resistance *
Loop With Home-Run Connected At Cabinet
* To be filled out by the Designer
Loop Numbe r
L μH
RΩ
Q >5
Megger
> 500 Meg Ω
Pass /Fail
1 2 3 4 5 6 7 8 9 10
Equipment Used: Loop Analyzer Model:________________
Megger Model:___________________
Loop Analyzer Make:_________________
Megger Make:____________________
Test Completed By:
Date:
Witness:
_________________ Signature
___________
_________________________ Signature
_________________ Print Name
Detector Loop Inductance & Resistance Test Form Rev. December 8, 2009
_________________________ Print Name
Page 2 of 2
DETECTOR ACCURACY VERIFICATION TEST: VOLUME (11/20/09) Site: ___________________________________________________________________ Date:_______________________ Time:_______________________________________ Objective: To verify and demonstrate the functionality and accuracy of volume for the detector locations. Prerequisites: Detector and cabinet installation must be complete. Lane must be open to traffic. ATMS Inspector must be present during testing. Test Equipment: 1. Stop watch
2. Traffic count board
Success Criteria: Volume obtained from each detector for each lane of traffic will be within +/10% of each sample size. Sample size will be ten minutes, or 50 vehicles, whichever comes first. Traffic will be running at typical free-flowing speed and condition. Test Instructions: 1. Record the observed actual hand count volume and detector counts for ten minutes, or 50 vehicles, whichever comes first. 2. Record the volume of vehicles detected by the sensor over the test period. 3. Subtract hand count volume from detector count volume and then divide by the hand count volume. Multiply by 100 to get the % accuracy 4. Indicate pass if result is +/- 10%. 5. Adjust sensitivity and repeat if % accuracy is out of range. Volume Test Results: Lane #: Test Duration (min:sec): Observed Hand Count Volume: Detector Count Volume (from Laptop): % Accuracy ( = 100 x (detector count - hand count)/(hand count) ): Pass or Fail (Pass if accuracy is < +/- 10%): Sensitivity Setting: Test Completed by (Installerâ&#x20AC;&#x2122;s Tester): Date: Test Inspected by (ATMS Inspector):
Non Intrusive Detector - Volume Test Form November 20, 2009
Page 1 of 1
OCCUPANCY ACCURACY VERIFICATION TEST (11/20/09) Site: ___________________________________________________________________ Date:_______________________ Time:_______________________________________ Objective: To verify and demonstrate the functionality and accuracy of occupancy for the detector locations. Prerequisites: Detector and cabinet installation must be complete. Lane must be open to traffic. ATMS Inspector must be present during testing. Test Equipment: 1. Stop watch 2. Traffic count board 3. Laptop Success Criteria: Occupancy obtained from each detector for each lane of traffic will be within +/- 5% of each sample size. Sample size will be three minutes. Traffic will be running at typical free-flowing speed and condition. Test Instructions: 1. Record the observed actual hand count occupancy and sensor counts for three (3) minutes. 2. Record the occupancy of vehicles detected by the sensor over the test period. 3. Subtract hand count volume from detector count volume and then divide by the hand count volume. Multiply by 100 to get the % accuracy 4. Indicate pass if result is +/- 5%. 5. Adjust sensitivity and repeat if % accuracy is out of range. Occupancy Measurements # Of Axles Vehicle Length (Appx.) 2 20 Ft. 3 >3
30 Ft- 40 Ft. >40 Ft.
Use the chart above to determine the number of axles by vehicle length. Choose a populated lane and monitor the occupancy of the lane for three (3) minutes. Use the chart on the next page to complete the test.
Test Completed by: (Installerâ&#x20AC;&#x2122;s Tester)
Date: _____________________
Test Inspected by: (ATMS Inspector)
Date: _____________________
Non Intrusive Detector â&#x20AC;&#x201C; Occupancy Test Form November 20, 2009
Page 1 of 2
Occupancy Test Results:
Lane #:
Time Duration (min:sec):
Observed Occupancy Counts
2 Axle
3 Axle
>3 Axle
Non Intrusive Detector â&#x20AC;&#x201C; Occupancy Test Form November 20, 2009
Occupancy (from Laptop) 2 Axle
3 Axle
>3 Axle
% Accuracy (=100 x (laptop observed)/(observed)
Page 2 of 2
Pass/Fail Pass if < +/- 5%
Sensitivity Setting
DETECTOR ACCURACY VERIFICATION TEST: SPEED (11/20/09) Site: ________________________________________________________________ Date: ______________________________ Time: _____________________________ Objective: To verify and demonstrate the functionality and accuracy of speed for detector locations. Note that this test is applicable to Wavetronix Smart Sensor 105 units that compute rolling average speed. Also note that this speed testing is not required for freeway on/off ramps, only for mainline detection. Prerequisites: Detector and cabinet installation are complete. Lane must be open to traffic. ATMS Inspector must be present during testing. Test Equipment: 1. Calibrated Radar Gun 2. Stop Watch 3. 2-Way Radios 4. Laptop Procedure: 1. Record distance L from radar gun to detector site. 2. Record offset O from center of each lane to radar gun site. 3. Compute the resultant angle theta ( = inverse tangent (O / L) ), which is the angle between radar gun beam and vehicle travel direction. 4. Compute cosine theta, which is the speed correction factor for the measurement angle. 5. Ensure that Detector unit is functioning, and that rolling average speed is being recorded. 6. Set the interval on the detector unit to 3 minutes. 7. Record the individual speeds of 16 consecutive vehicles using radar gun. If measuring consecutive vehicles is not possible, measure speeds for as many vehicles in the lane as possible, for 16 vehicles or 3 minute time period, whichever comes first. 8. Simultaneously to recording the 16th vehicle, or completing the 3 minute time period, immediately record the current Detector Mean Speed as indicated at that moment by the Detector unit. 9. Compute the mean (average) speed of the 16 vehicles, based on radar gun readings. 10. Compute the Modified Radar Gun Mean Speed ( = radar gun mean speed / cosine theta ), if needed, if radar gun is not shooting head-on at vehicles. 11. Compare the Modified Radar Gun Mean Speed to the Detector Mean Speed. Pass if difference < 5 mph. If test does not pass, adjust the sensitivity of the sensor and retest. 12. Repeat for each lane. Set-up Data: Radar Unit Type, Model, and Serial #: ________________________________________________ Record Distance L from Radar Site to Detector Site: _____________________________________ Record Offset O from Radar Site to Center of Lane 1: ____________________________________ Compute Theta 1:________________________ Compute Cosine Theta 1: ____________________ Record Offset from Radar Site to Center of Lane 2: ______________________________________ Compute Theta 2:________________________ Compute Cosine Theta 2: ____________________ Record Offset from Radar Site to Center of Lane 3: ______________________________________ Compute Theta 3:________________________ Compute Cosine Theta 3: ____________________ Record Offset from Radar Site to Center of Lane 4: ______________________________________ Compute Theta 4:________________________ Compute Cosine Theta 4: ____________________ Record Offset from Radar Site to Center of Lane 5: ______________________________________ Compute Theta 5:________________________ Compute Cosine Theta 5: ____________________
Non Intrusive Detector SS 105 Speed Test Form November 20, 2009
Page 1 of 2
Lane#:
Vehicle #: 1
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Radar Gun Mean Speed (mph): Cosine theta: Modified Radar Gun Mean Speed (mph): Detector Mean Speed (mph): Pass or Fail (Pass if Modified Radar Gun and Detector Mean Speeds are within +/- 5 mph): Sensitivity Setting: Does Controller Properly Record Occupancy?: Test Completed by (Installerâ&#x20AC;&#x2122;s Tester): Date: Test Inspected by (ATMS Inspector):
Non Intrusive Detector SS 105 Speed Test Form November 20, 2009
Page 2 of 2
DETECTOR ACCURACY VERIFICATION TEST: SPEED (11/20/09) Site: ________________________________________________________________ Date: ______________________________ Time: _____________________________ Objective: To verify and demonstrate the functionality and accuracy of speed for detector locations. Note that this test is applicable to Wavetronix Smart Sensor HD units that compute rolling average speed. Also note that this speed testing is not required for freeway on/off ramps, only for mainline detection. Prerequisites: Detector and cabinet installation are complete. Lane must be open to traffic. ATMS Inspector must be present during testing. Test Equipment: 1. Calibrated Radar Gun 2. Stop Watch 3. 2-Way Radios 4. Laptop Procedure: 1. Record distance L from radar gun to detector site. 2. Record offset O from center of each lane to radar gun site. 3. Compute the resultant angle theta ( = inverse tangent (O / L) ), which is the angle between radar gun beam and vehicle travel direction. 4. Compute cosine theta, which is the speed correction factor for the measurement angle. 5. Ensure that Detector unit is functioning, and that rolling average speed is being recorded. 6. Set the interval on the detector unit to 3 minutes. 7. Record the individual speeds of 16 consecutive vehicles using radar gun. If measuring consecutive vehicles is not possible, measure speeds for as many vehicles in the lane as possible, for 16 vehicles or 3 minute time period, whichever comes first. 8. Simultaneously to recording the 16th vehicle, or completing the 3 minute time period, immediately record the current Detector Mean Speed as indicated at that moment by the Detector unit. 9. Compute the mean (average) speed of the 16 vehicles, based on radar gun readings. 10. Compute the Modified Radar Gun Mean Speed ( = radar gun mean speed / cosine theta ), if needed, if radar gun is not shooting head-on at vehicles. 11. Compare the Modified Radar Gun Mean Speed to the Detector Mean Speed. Pass if difference < 5 mph. If test does not pass, adjust the sensitivity of the sensor and retest. 12. Repeat for each lane. Set-up Data: Radar Unit Type, Model, and Serial #: ________________________________________________ Record Distance L from Radar Site to Detector Site: _____________________________________ Record Offset O from Radar Site to Center of Lane 1: ____________________________________ Compute Theta 1:________________________ Compute Cosine Theta 1: ____________________ Record Offset from Radar Site to Center of Lane 2: ______________________________________ Compute Theta 2:________________________ Compute Cosine Theta 2: ____________________ Record Offset from Radar Site to Center of Lane 3: ______________________________________ Compute Theta 3:________________________ Compute Cosine Theta 3: ____________________ Record Offset from Radar Site to Center of Lane 4: ______________________________________ Compute Theta 4:________________________ Compute Cosine Theta 4: ____________________ Record Offset from Radar Site to Center of Lane 5: ______________________________________ Compute Theta 5:________________________ Compute Cosine Theta 5: ____________________
Non Intrusive Detector SS HD Speed Test Form November 20, 2009
Page 1 of 2
Lane#:
Vehicle #: 1
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
Speed from Radar Gun Display (mph)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Radar Gun Mean Speed (mph): Cosine theta: Modified Radar Gun Mean Speed (mph): Detector Mean Speed (mph): Pass or Fail (Pass if Modified Radar Gun and Detector Mean Speeds are within +/- 5 mph): Sensitivity Setting: Does Controller Properly Record Occupancy?: Test Completed by (Installerâ&#x20AC;&#x2122;s Tester): Date: Test Inspected by (ATMS Inspector):
Non Intrusive Detector SS HD Speed Test Form November 20, 2009
Page 2 of 2
RAMP METER LOCAL FIELD OPERATIONS TEST Site:
_________________________________________________________________
Objective: To demonstrate that all Ramp Meter hardware, cables, connectors operate correctly and are in conformance with the manufacturerâ&#x20AC;&#x2122;s requirements. Prerequisites: 1.
All Ramp Meter related construction at the site must be complete.
Success Criteria: All components have been installed and operate properly. Test Results: Equipment Assembly
Yes/No/N.A.
Have all demand detection zones been installed per plans? Have all passage detection zones been installed per plans? Have all max queue detection zones been installed per plans? Have all intermediate queue detection zones been installed per plans? Have all exit ramp detection zones been installed per plans? Do all demand detection zones properly visually register calls? Do all passage detection zones properly visually register calls? Do all max queue detection zones properly visually register calls? Do all intermediate queue detection zones properly visually register calls? Do all exit ramp detection zones properly visually register calls? Has the right side signal assembly been installed per plans? Has the left side signal assembly been installed per plans? Has the mast arm signal assembly been installed per plans? Has the right side advance-flashing beacon been installed per plans? Has the left side advance-flashing beacon been installed per plans? Do all right side signal assembly heads operate properly? Do all left side signal assembly heads operate properly? Do all mast arm signal assembly heads operate properly? Does the right side advance-flashing beacon operate properly? Does the left side advance-flashing beacon operate properly? Test Completed by:
Date:
Witness:
___________________________ Signature ___________________________ Print Name
____________
_____________________________ Signature _____________________________ Print Name
Ramp Meter Local Field Operations Test Form Rev. March 23, 2004
Page 1 of 1
VARIABLE MESSAGE SIGN (VMS) LOCAL FIELD OPERATIONS TEST 1.
Introduction
This document outlines the Local Field Operations Test for the Variable Message Sins (VMS) System. Each system consists of a VMS, a field cabinet and interconnections. This test is to be performed on site and at UDOT prior to the Design/Builder accepting delivery of the VMS from UDOT. The purpose of the test is to ensure that the system is operational and that the sign has not been damaged. 2.
Operations Criteria
Each system must pass all items in this procedure. 3.
Reference Documents
VMS systems User Manual
Maintenance Manual for UDOT FP9000 Display Control VMS System Functional Requirements Specification Laptop Maintenance Computer Operatorâ&#x20AC;&#x2122;s Manual 4.
Test Details
Date of Test:
_______________________________
Test Performed By:
_________________________
UDOT Witness :
___________________________
5.
Sign and Controller Details
Serial Number of VMS Assembly:
________________________
Serial Number of Field Cabinet Assembly:
________________________
Variable Message Sign (VMS) Local Field Operations Test Rev. March 23, 2004
Page 1 of 6
6.
Software Revisions
Controllerâ&#x20AC;&#x2122;s EPROM (U20) Controllerâ&#x20AC;&#x2122;s EPROM (U21) Power Supply #1 EPROM Power Supply #2 EPROM Power Supply #3 EPROM Power Supply #4 EPROM Dot Driver Interface EPROM 7.
EPROM P/N
Revision
Checksum
Test Equipment and Arrangements
UDOT will furnish LLC Test Software. A laptop computer will be provided by the Designer/Builder for the purpose of performing the test. 8.
Test Procedures
8.1
Pre-Test Visual Inspection
The following is to be performed PRIOR to applying power to the system. 8.1.1
VMS Assembly
a)
Check to see that there is no obvious sign of damage to the equipment
____________
b)
Check that all equipment inside the cabinet is properly secured (No loose or missing screws, properly seated screws, etc.)
____________
c)
Check that there are no exposed 120V terminals inside the cabinet
____________
d)
Check that all display modules are properly seated and secured.
____________
e)
Check that all lamps are properly seated.
____________
8.1.2
Field Cabinet Assembly
a)
Check that all equipment inside the cabinet is properly secured (No loose or missing screws, properly seated screws, etc.)
____________
b)
Check that there are no exposed 120V terminals inside the cabinet.
____________
8.2
Basic Operation Test
The following is to be performed AFTER applying power to the system. 8.2.1
Field Cabinet Assembly, electrical
Variable Message Sign (VMS) Local Field Operations Test Rev. March 23, 2004
Page 2 of 6
8.2.1.1 General a)
Check that the FP9000 is powered up (check that a message appears on the LCD panel)
____________
b)
Check that power is available at all duplex receptacles.
____________
8.2.1.2 Fluorescent Lamp a)
Check that the fluorescent lamp turns on when the enclosure door is opened.
____________
b)
Depress the door switch and check that the fluorescent lamp turns off.
____________
8.2.1.3 Ventilation Fan a)
Check that when the fan thermostat is adjusted to a temperature greater than ambient, the fan turns off.
____________
b)
Check that when the fan thermostat is adjusted to a temperature less than ambient, the fan turns on.
____________
8.2.1.4 Heater a)
Check that when the heater thermostat is adjusted to a temperature greater than ambient, the heater is on.
____________
b)
Check that when the heater thermostat is adjusted to a temperature less than ambient, the heater turns off.
____________
8.2.2
VMS Assembly, Electrical (In accordance with NEC)
8.2.2.1 General a)
Check that power is available at all duplex receptacles.
____________
8.2.2.2 Fluorescent Lamps a)
Check that the fluorescent lamps turn on when the enclosure door is open.
____________
b)
Check that the fluorescent lamps turn off when the enclosure door is closed.
____________
c)
With the enclosure door closed, turn the fluorescent lamps on using the over-ride switch inside the enclosure.
____________
Variable Message Sign (VMS) Local Field Operations Test Rev. March 23, 2004
Page 3 of 6
8.2.2.3 Ventilation Fans a)
Check that when the fan thermostat is adjusted to a temperature greater than ambient, the fans turns off.
____________
b)
Check that when the fan thermostat is adjusted to a temperature less than ambient, the fans turn on.
____________
8.2.2.4 Heater Cable a)
Check that when the heater thermostat is adjusted to a temperature greater than ambient, the heater cable is on.
____________
b)
Check that when the heater thermostat is adjusted to a temperature less than ambient, the heater cable turns off.
____________
8.2.2.5 Door Open Detection Switch a)
Check that when the enclosure door is open, the 1st LED on the I/O panel is on.
____________
b)
Depress the door open detection switch (or close the door) and check that the LED turns off.
____________
8.2.3
Operational Test
All tests will be performed with controller address set to #1, unless otherwise specified. The UTAH Maintenance Computer Software (Laptop software supplied by Mark IV) will be used in this section. 8.2.3.1 LCD Display a)
Check that the LCD display of the controller identifies the address of the controller, the I.D. / revision of the controller software, the time and the date. ____________
8.2.3.2 Polling a)
Connect the laptop to Port 2 of the controller. With the modes switch set to LOCAL, poll the controller with laptop computer set to 1200 baud, no parity, 8 data bits and 1 stop bit. Check that the controller responds to the poll.
____________
8.2.3.3 Sign Command 1-32 (0x1 to 0x20) a)
Download a library of test messages. Verify that messages can be displayed by selecting the corresponding message number.
____________
8.2.3.4 Sign Command 0 (0x00) – “BLANK” a)
Display any message on the sign. Execute this command. Check that the sign is blanked.
Variable Message Sign (VMS) Local Field Operations Test Rev. March 23, 2004
____________ Page 4 of 6
8.2.3.5 Sign Command 34 (0x22) – “STATUS” a)
b)
Execute this command with a message displayed. Check that the controller responds with the current state but does not alter the message displayed.
____________
Check that the status returned by the controller includes: 1.
Currently displayed message
____________
2.
Control source
____________
3.
Front light sensor reading: a) Shine a bright light directly on the sensor, verify reading (non-zero value)
____________
Top light sensor reading: a) Shine a bright light directly on sensor, verify change in reading (non-zero value)
____________
Backlight sensor reading: a) Shine a bright light directly on sensor, verify change in reading (non-zero value)
____________
6.
Internal temperature
____________
7.
External temperature
____________
8.
Last Error
____________
9.
Pixel failure, turning on
____________
10.
Pixel failure, turning off
____________
11.
Module failure
____________
12.
Power failure flag
____________
4.
5.
8.2.3.6 Sign Command 35 (0x23) _ “RESET” a)
Execute this command with a message displayed. Check that this command blanks the sign face and then resets the controller.
____________
8.2.3.7 Sign Command 36 (0x24) – “ALL ON” a)
Execute this command with a message displayed. Check that this command turns all pixels on.
Variable Message Sign (VMS) Local Field Operations Test Rev. March 23, 2004
____________
Page 5 of 6
8.2.3.8 Sign Command 38 (0x26) – “ON/OFF” a)
Execute this command with a message displayed. Check that the controller responds with the current state and cycles all the pixels On and Off.
____________
8.2.3.9 Sign command 39 (0x27) – “Row/Column” a)
Execute this command. Verify that each row and each column are displayed Sequentially.
9.
Comments (record any pertinent comments pertaining to the test):
Variable Message Sign (VMS) Local Field Operations Test Rev. March 23, 2004
____________
Page 6 of 6
WEIGH IN MOTION (WIM) LOCAL FIELD OPERATIONS TEST _________________________________________________________________
Site #: Objective:
To demonstrate that the hardware, cables, connectors, and sensors operate correctly at the WIM field site. Prerequisites:
1.
All construction for the site has been completed and final road surface has been constructed.
2.
All Detector Loop Inductance & Resistance Tests have been successfully performed for all inductive loops installed as part of this WIM site. Piezo calibration has been successfully performed. All connecting cabling has been properly installed. 5-Day pre-notification has been sent to the Owner.
3. 4. 5.
Test Equipment:
1. 2. 3.
Laptop computer Digital Multi-meter or Scope Meter Current Manufacturer’s Test Program
Cabinet Equipment
Equipment WIM Processor
Make
Model
Serial Number
Test Results
Is all equipment securely bolted in rack? Have all cables and connectors have been installed? Record DC cabinet voltage Record AC cabinet voltage Is AC power available at each outlet? Does GFI button properly trip and reset? Does heater turn on when thermostat is set above ambient temp? Does heater turn off when thermostat is set below ambient temp? Is heater thermostat set to low position? Does fan turn on when thermostat is set below ambient temp? Does fan turn off when thermostat is set above ambient temp? Is fan thermostat set at 95°F (+/- 5°F)? Does cabinet light function with only the front door open? Does cabinet light function with only the rear door open? Weigh In Motion (WIM) Local Field Operations Test Rev. March 23, 2004
Page 1 of 2
Does cabinet light go off with both door switches depressed? Does power on/off function work properly? Is all equipment securely attached within the cabinet? Is the cabinet fan operating? Are the piezo sensors operational? Is the controller properly processing all of the relevant data from each sensor at the site? Has each sensor been properly calibrated, and is providing accurate measurements? Test Completed by: _____________________ Signature
Date:
Witness :
____________
___________________ Signature
_____________________ Print Name
Weigh In Motion (WIM) Local Field Operations Test Rev. March 23, 2004
___________________ Print Name
Page 2 of 2
Form C-111 Rev. 12-12
UTAH DEPARTMENT OF TRANSPORTATION
INSPECTOR’S DAILY REPORT NOTE: PRIOR TO STARTING ANY INSPECTION ON A PROJECT, ALWAYS REVIEW AND HAVE IN YOUR POSSESSION THE PROJECT SPECIFICATIONS, STANDARD DRAWINGS, AND PROJECT SCHEDULE PERTAINING TO THE SPECIFIC ITEMS INSPECTED!!!
PIN No.:
Project No:
Project Name:
Prime Contractor: Project Time: □ Working Day □ Calendar Day □ Completion Date
Date:
Prime Contractor Hrs. Worked: From___________ AM/PM to____________ AM/PM Shift: ____________ Contractor/Subcontractors:
Hrs:
Supervisor: Skilled:
Equip. Used by Crew/Subconctractor:
Work In Progress 1
Day Of Week SMTWTFS Weather: Unskilled:
Form C-111 Rev. 12-12
CPM Activity ID
Item Number
Item Description / Type of Work
Project Location
Brief Description of Work
PROBLEMS OR DELAYS HINDERING JOB PROGRESS: (Describe any situations that
are delaying work on the project.)
INSPECTION: (Address quality, including repeated deficiencies, of workmanship and methods used to assure control test and materials incorporated are in compliance with plans and specifications. List name(s) of Materials Tester and tests performed.)
VERBAL INSTRUCTIONS RECEIVED: (List any directions received or decisions by RE. Indicate “None” if none received.)
REMARKS: (Record conversations, verbal agreements, and instructions exchanged by Inspector with Contractor. Discuss any conflicts in plans, specifications, or instructions. Indicate “None” if none identified.)
RESULTS OF SAFETY INSPECTION/ACCIDENTS: (Note safety violations/concerns and corrective action taken. Indicate phase of work where violations occurred. Note accidents on the project, time, location, details & name of Investigating Officer. Take pictures of accident and traffic control if accident is within work zone. Indicate “None” if none identified.)
TRAFFIC CONTROL: (Must have current copy of Traffic Control Plan (TCP). Note time of day traffic control checked, location of any issues found and corrective action taken. Include pictures and/or video if available.)
Is the traffic control set up according to the approved traffic control plan? (Taper length, drum spacing, location of arrow board, proper signs & spacing, etc.) □Yes □No
2
Form C-111 Rev. 12-12
Are the traffic control devices clean? □Yes
□No
Are devices in acceptable condition? □Yes
□No
devices deficient, and percent deficient of total.)
devices deficient, and percent deficient of total.)
(If No, describe location, number of
(If No, describe location, number of
Have all conflicting pavement markings been removed? □Yes of conflicting markings.)
□No
(If No, list location
Have all unneeded devices/signs been removed per the hazard mitigation sheet? □Yes □No (If No, list location of devices/signs that have not been removed)
Has there been a major change in the traffic pattern? □Yes measures taken to warn the traveling public of the change.)
□No
(If Yes, describe
EROSION CONTROL/ENVIRONMENTAL ISSUES: (Discuss any issues related to erosion control, environmental commitments and storm events. Indicate “None” if none identified. Has a weekly inspection been done on erosion control items? Only document if you are the ECS or the ECS is not on site)
UPCOMING WORK: (Indicate next phase of work anticipated by the Contractor and the
approximate date of the start of this work. Indicate any changes to the schedule, if any, and the possible need for additional materials tests.)
UTILITY WORK: (List/Discuss any work, including location, being performed by Utility Companies/Contractors)
Utility Contractor Name
Utility Work This Day Description of Work Performed
3
Form C-111 Rev. 12-12
OTHER: (Events of note not covered above)
INSPECTOR’S SIGNATURE:____________________________________DATE:______________
4
C120 (11/12)
CONSTRUCTION PROCESS REVIEW REPORT Project No.
PIN #
Location
Contractor
Resident Engineer/Consultant Contract $
Review Date
District Engineer
Budget $
Region Project Manager
Contract Time
P+T
Change Order as % Contract
$
Time Ext
No
Completion Date
Calendar Days
Change Orders
Yes
% Time Elapsed
% Project Complete
NTP
Review Participants Name
Organization
Title
Review Questions All â&#x20AC;&#x153;noâ&#x20AC;? answers require action by the Resident Engineer (see below)
Y
N
File Organization/Document Management 1
Is documentation being stored in ProjectWise?
Subcontracts (Federal aid projects only) 2
Has the engineer randomly selected a subcontract to review to verify the required federal aid provisions (as listed on the C-116) are included in the agreement?
Labor/EEO Compliance (Federal aid projects only) 3
Are payrolls being entered into PDBS and within 7 days of the end of the pay period?
4
Are subcontracts (C-115), including all dates, being entered and checked in PDBS? (Required before subcontractors can enter
1
payrolls)
5
Have Bulletin Board Reviews been conducted in a timely manner (throughout the project construction) and documented on form C131?
6
Are form(s) C133 (Harassment, Intimidation & Coercion) in the project file and is the roster being checked against payrolls?
7
Have form(s) 1444 been submitted to DOL for wage determination on positions not currently listed on the wage rate schedules?
8
Have training hours been reported into PDBS?
9
Has prompt payment information been entered into PDBS within 15 days from the date of Contractor receiving payment from UDOT?
10
Have all Civil Rights requirements been entered into PDBS prior to processing the last progress payment?
Contract Time - Schedule 11
Is there a baseline CPM schedule that has been reviewed, accepted, dated and signed by the RE?
12
Is there a CPM schedule update corresponding to the last partial estimate processed?
13
Are time extensions supported in accordance with contract requirements?
14
Have contract time suspensions been coordinated with the District Engineer?
Inspectorâ&#x20AC;&#x2122;s Daily Reports 15
Do daily diary reports contain all information per the Construction MOI?
16
Has the person reporting the information signed the report or included his/her name in PDBS?
Materials Acceptance (Select at least three bid items) 17
Have MS&T Requirements been followed?
18
Is the required supporting documentation in the project file for items paid?
19
Are exceptions to certification procedures being reported on the C196 A?
20
Is documentation in the file certifying each steel/iron item meets Buy America Requirements (i.e. Manufacturer Certification of Compliance Letters including heat numbers that can be tracked from smelting, through all manufacturing processes to final product)?
21
Are calculations in the file for steel/iron of unknown origin demonstrating that total cost is one-tenth of one percent of total contract cost or $2500, whichever is greater?
Changes and Extra Work 22
Is extra work covered by an executed change order or C107?
2
23
Is the change order process (08B-10) being followed?
24
If a C107 has been completed on any portion of the work, has a C100 (Change Order) been completed within 30 days of the C107?
Traffic Control/Safety 25
Has the contractor’s traffic control plan been reviewed and accepted by the RE and has it been stamped by a PE?
26
Have Daily Traffic Control Inspection Reports been submitted on a weekly basis (required to have 4/day)?
27
Are safety inspections being performed by the Region Safety Manager?
28
If so, Is the RE or Field Engineer attending these Inspections?
Environmental 29
Is the Environmental Document in Project Wise and has the RE reviewed it for environmental commitments?
30
Are there specific Environmental commitments for this project?
31
Are these commitments being tracked during construction?
32
Has the project been informally/formally partnered?
33
Are partnering surveys being completed and entered on the UDOT website?
34
Have all required project personnel completed all required phases of partnering as instructed by the UDOT Partnering Field Guide?
Partnering
Contractor Rating 35
Are Contractor Ratings (Form C-119) being completed on a timely basis and as per contract specs?
Project Site/Materials Lab
Reviewed by:
36
Does the inspector and lab personnel have a copy of the contract/special provisions?
37
Is acceptance testing being performed by certified personnel?
38
If applicable, are asphalt binder samples being taken in accordance with requirements and sent to the Central Laboratory weekly?
39
Is there a copy of the contractor’s Traffic Control Plan on the project site?
40
Are traffic control requirements being followed?
41
Is the lead inspector familiar with the CPM schedule and the items that are on the critical path?
42
Does the lead inspector have a copy of the Inspector’s Manual and MS&TR?
43
Is there a copy of the approved SWPPP on the project?
44
Does the erosion control appear satisfactory based on the approved SWPPP? Date:
3
Current Project Status:
Materials Review: Bid Item #
Description
Comments
General Comments: Description
Comments
For Resident Engineer’s Use:
Explain corrective action to be taken for any deficiencies discussed or “no” answers and return to Deputy Construction Engineer within 7 calendar days of review date.
No.
Corrective Action
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Signature:
Date:
4
Form: C-150
UDOT CULVERT INSPECTION FORM State Route: Reference Post: PIN / Project:
Alignment
Vertical
Comments Horizontal
Joint Damage
Invert Damage
Material (CMP, HDPE, PVC, RCP)
Dents
Length (ft)
Span (S) (in)
Coating Damage
Diam. (in)
Rise (R) (in)
Manual / Visual Inspection Barrel Distort.
Pipe Arch
Arch
Pipe Arch
Physical Characteristics
Pipe Type
Circular
Storm Drain
Irrigation
Route / R.P. or Alignment
Drainage Cross Culvert
Location
Arch
Abrasions
Circular
Date: Inspector: Contractor:
C-160 REV. 4/06
PROJECT VISUAL INSPECTION FOR MATERIALS FURNISHED FOR STATE AND FEDERAL AID HIGHWAY PROJECTS Project No: Project Location: Contractor: Subcontractor: Supplier:
(Manufacturer or Vendor)
Item Specification (Bid Item and Description): Bid Item (s): Related Materials Standards:
Description* of Material Placed:
Description* of Placement Practices:
*See Related Specifications and Minimum Sampling and Testing Requirements for details on what to address.
I hereby acknowledge that the above documentation is a true representation of the material and placement practices in the field.
Technical Inspector
Date
Resident Engineer
Date
NOTE:
Copy to be retained in Project Materials Certification File
Construction Inspection Guide
Construction Materials Forms
UTAH DEPARTMENT OF TRANSPORTATION MATERIALS REQUEST FOR TESTING
Form-247 Rev. 3/2002
PROJECT NAME
PROJECT NO.:
CHARGE I.D.
ORG. NO. STATION or
Or Auth no.:
Source
TASK NUMBER C
A
C
A
M.
C
E
O
N
O
N
T.
O
X
M
A
M
A
S.
E
P
P
L
P
L
L
Y
L
Y
C
E
S
E
S
R
O
S
T
I
T
I
E
F
I
E
S
E
S
E
LAB NUMBER
F.
P
A N
O T
O
C
H
I
E
E
L
M
R
E
M
N
A
T
L
N
3 Copies To Accompany Each Material Shipment To Central Lab Submitted To:
By: Region Materials Engineer
Date
Utah Department of Transportation Paint Sample Identification Form Reference: Minimum Sampling and Testing Requirements Section 02765 http://www.udot.utah.gov/main/f?p=100:pg::::1:T,V:1397, Quality Management Plan 513 Specification Section 027655 Materials 932
Project Name Project Number
Project CID
Supplier
Pavement Marking Type
Applicator Yard Tote Number
Sample Date
Batch Number
APPLICATOR REQUIREMENTS I Certify as follows: That the sample was obtained in accordance with UDOT requirements. Applicator's Agent
UDOT'S PAINT SAMPLING WITNESS STATEMENT I certify that I witnessed the sample represented by this form, and that it was obtained in accordance with UDOT requirements. UDOT Agent
Form - 513 REV. 2.09
Form - 348 rev. 10/12 UTAH DEPARTMENT OF TRANSPORTATION WEEKLY DENSITY REPORT Project Name:
Report No.:
Project No:
Week Ending:
Project Pin:
Material:
Pit or source:
Item #:
Material Type: Roadway Excavation
Test Date: Test Station and Offset 1 2 3 4 5 Limits - Sta From: Remarks:
Lab Max Dry Lab Optimum Density Moisture
to
to
to
T99 or T180
to
Field Dry Density
T99 or T180
Grade Reference
Thickness(in)
Field Dry Density
Volume (CY) =
Grade Reference
Thickness(in)
Field Dry Density
T99 or T180
Volume (CY) =
Lab / Sample No. or ID
Grade Reference
Thickness(in)
Field Dry Density
Quantity Reported this date (CY):
Field % Moisture
Avg. Compaction
0
Volume (CY) =
0
Tested By
Probe Depth
Tested By
Probe Depth
Tested By
Probe Depth
Tested By
#DIV/0!
% Compaction
#DIV/0!
% Compaction
#DIV/0!
% Compaction
#DIV/0!
#DIV/0!
Total Quantity to Date (CY): Date:
Probe Depth
#DIV/0!
to Area (sy) = M.S.:
Field % Moisture
Avg. Compaction
0
% Compaction
#DIV/0!
to Area (sy) = M.S.:
Field % Moisture
Avg. Compaction
0
Lab / Sample No. or ID
Field % Moisture
#DIV/0!
to
Offset From:
0
Volume (CY) =
Lab / Sample No. or ID
Offset From:
Lab Max Dry Lab Optimum Density Moisture
Thickness(in)
Untreated Base Course Type 3
Avg. Compaction
0
Area (sy) = M.S.:
Lab Max Dry Lab Optimum Density Moisture
Grade Reference
to
Offset From:
Area (sf) = 0 Daily Standard Count D.S.:
Project Engineer:
Lab / Sample No. or ID
Area (sy) = M.S.:
Lab Max Dry Lab Optimum Density Moisture
Quantity Previously Reported (CY):
T99 or T180
Offset From:
Area (sf) = 0 Daily Standard Count D.S.:
Test Date: Test Station and Offset 1 2 3 4 5 Limits - Sta From: Remarks:
Untreated Base Course Type 2
Area (sf) = 0 Daily Standard Count D.S.:
Test Date: Test Station and Offset 1 2 3 4 5 Limits - Sta From: Remarks:
Untreated Base Course Type 1
Area (sf) = 0 Daily Standard Count D.S.:
Test Date: and Offset Test Station 1 2 3 4 5 Limits - Sta From: Remarks:
MSE Select Fill Embankment for Bridge
Granular Borrow
Backfill Placement
0
UTAH DEPARTMENT OF TRANSPORTATION AGGREGATE PHYSICAL PROPERTIES REPORT
PROJECT NAME : PROJECT NO: PROJECT PIN: RESIDENT ENGINEER:
SUPPLIER: SOURCE / PLANT: MATERIAL TYPE: SPECIFICATIONS: REQUIRED TESTS:
SAMPLE DATE: TEST DATE:
SAMPLED BY: TESTED BY: LOT LIMITS AND QUANTITY (IF APP)
ITEM #: PRODUCTION DAY (IF APP): PLACEMENT TYPE (IF APP): AGGREGATE CLASS (IF APP):
STATION FROM: OFFSET FROM: OFFSET TO: THICKNESS (in): LENGTH: AREA (SY) VOLUME (CY)
QUANTITY PREV REPORTED: 0 TOTAL QUANTITY TO DATE: 0
TO: LT/RT LT/RT 0 0 0
SIEVE ANALYSIS ASTM C136 / AASHTO T11 / AASHTO T27
Sieve Size
Sample 1 ID:
Sample 2 ID:
Sample 3 ID:
Sample 4 ID:
Sample 1 Sta:
Sample 2 Sta:
Sample 3 Sta:
Sample 4 Sta:
Sample 1 O/S:
Sample 2 O/S:
Sample 3 O/S:
Sample 4 O/S:
Sample 1 Accum. % Passing
Sample 2 Accum. % Passing
Sample 3 Accum. % Passing
Spec:
Sample 4 Accum. % Passing
Specifications
450 mm (18")
#N/A
375 mm (15")
#N/A
300 mm (12")
#N/A
250 mm (10")
#N/A
225 mm (9")
#N/A
200 mm (8")
#N/A
150 mm (6")
#N/A
125 mm (5")
#N/A
100 mm (4")
#N/A
75.0 mm (3")
#N/A
63.0 mm (2-1/2")
#N/A
50.0 mm (2")
#N/A
37.5 mm (1-1/2")
#N/A
25.0 mm (1")
#N/A
19.0 mm (3/4")
#N/A
12.5 mm (1/2")
#N/A
9.5 mm (3/8")
#N/A
6.3 mm (1/4")
#N/A
4.75mm (No. 4)
#N/A
2.36 mm (No. 8)
#N/A
2.00 mm (No. 10)
#N/A
1.18mm (No.16)
#N/A
0.600 mm (No.30)
#N/A
0.425mm (No. 40)
#N/A
0.300mm (No. 50)
#N/A
0.180mm (No. 80)
#N/A
0.150mm (No.100)
#N/A
0.075mm (No. 200)
#N/A
ASTM C117 AASHTO T11 Moisture Content, % AASHTO T255 Gauge Moisture Content, %
Difference
Difference
Difference
Difference
AASHTO T310
0.0
0.0
0.0
0.0
Soil Classification AASHTO M145 Lab Max Dry Density / Opt Moisture T180 Modified REMARKS:
Opt Moisture, %= Max Density, pfc=
Opt Moisture, %= Max Density, pfc=
Opt Moisture, %= Max Density, pfc=
Opt Moisture, %= Max Density, pfc=
- 251 rev. 11/12 UTAH DEPARTMENT OF TRANSPORTATION CONCRETE CYLINDER TEST REPORT PROJECT NAME : PROJECT NO: PROJECT PIN: RESIDENT ENGINEER: PLACEMENT NO: PLACEMENT DATE: CONTRACTOR / SUB: SUPPLIER: SOURCE / PLANT:
MIX DESIGN NUMBER: TEST / CYLINDER ID: TEST TIME: REQ'D MIN STRENGTH (f'c):
ITEM #: TICKET NO: CRETE TEMP: SLUMP: FIELD No.
LOCATION: AMBIENT TEMP: AIR CONTENT: LAB No.
AGE
CAST DATE
BREAK DATE
STRENGTH (PSI)
0 0 0 0 0 0 0 0 0 0 0 0 0 AVERAGE 28-DAY STRENGTH: Cylinders Cast By: Cylinders Broke By:
AASHTO T 23, T 141, T 152, T 119
IA SAMPLE: d REMARKS:
Air Meter Number & Calibration Date
#1 #2 IA Samples must include Air Meter number and Calibration date.
#DIV/0!
BREAK TYPE
Form xxx Rev 06/12 Project Number: 0 Pin: 0 Project Name: 0 Item No and Desc: DENSITY TESTING SUMMARY Material Type: Testing Frequency:
#N/A
per
#N/A
#N/A BFSG = Below finish subgrade *Negative offset indicates LT and positive indicates RT
Test Date
138 / 348 Report No.
Supplier
Source
Line
MP / Station From
MP / Station To
O/S From
O/S To
FSG = Finish subgrade
Width
Area (SF) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12/30/2012
Thickness (in)
Area (SY) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Grade Ref.
CY 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Test Req'd #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A
Avg % Tests Taken Compaction
Tested By
1 of 2
C – 112 form Rev. 10/09
Letter of Certification Utah Department of Transportation CRASH CUSHION OR BARRIER END TREATMENT
This letter meets the requirements established in Standard Specification Section 02843, 1.5, B
I (Company Officer or on site installer)
affirm that the system(s) listed below have been installed
according to the Utah Department of Transportation Standard and Specification Section 02843 and Standard Drawings CC Series, and to the manufacturer’s specifications. Project #: Location:
Route #: (Project station number or mile post, median, left or right shoulder, or gore area)
UDOT System Type: (Refer to the current edition of Guidelines for Crash Cushion & Barrier End Treatments) Manufacturer and system name: Installation Company Name: Certified Installers Name: Prime Contractor:
Certified Installer or Company Officers Signature: Title: Print Name
Date:
Instructions: If multiple systems of the same UDOT Type and same manufacturer are placed on a project one (1) Letter of Certification may be submitted for all of the like systems listing location information and certified installer’s name for each system.
Form C106 (revised 05/12)
NOTICE OF UNACCEPTABLE WORK OR MATERIAL To: Project #: Location: This is to advise you the following described work or material does not comply with contract requirements. You are hereby directed to immediately take the following action: ITEM NO.
WORK OR MATERIAL / BASIS FOR REJECTION
QUANTITY
ACTION REQUIRED *
* 1) Remove and Replace 2) Correct Deficiency 3) Accept Price Reduction (shown) For work or material requiring acceptance of a price reduction, you may choose to remove and replace the work or material or correct the deficiency with the concurrence of the Resident Engineer. The replaced or corrected work or material is accepted or rejected based on contract specifications and the Departmentâ&#x20AC;&#x2122;s Quality Assurance Program. For work or material requiring removal and replacement, or corrective action, you may request a review to determine if the material may be allowed to remain in place with a price reduction. Concurrence and approval of the District Engineer and Region Materials Engineer is required when allowing unacceptable work or material to remain in place at a reduced price. A returned copy of this form letter with your signature indicating your choice of action is considered written request for Department approval. Attach any information relevant to the Departmentâ&#x20AC;&#x2122;s decision, including an engineering analysis, if applicable. Failure to Return a signed copy of this form letter with your choice of action within three working days indicates your acceptance of the required action indicated above. Sincerely,
Resident Engineer Action selected by Contractor: I, the Contractor or designated representative, return one copy of this form letter to the Resident Engineer with my choice of action indicated below: (Check one) 1.
Remove and replace
2.
** 3.
Correct deficiency
_____________________________________
Contractor or Authorized Representative
________________________
Title
Accept price reduction _______________________
Date
Concurrence and approval for Action 3: _______________________________________
**Region Materials Engineer
Date
_______________________________________
**District Engineer
Date
GENERAL INFORMATION This form is used to notify the Contractor of unacceptable work or material and to assist in making record of the acceptance decision. Unacceptable work or material is defined as: Work or material that does not meet the contract requirements; reject
(The Engineer rejects all materials not meeting the contract requirements. â&#x20AC;&#x201C; Section 01455)
Section 01455 requires the Contractor to immediately remove unacceptable material from the project site unless the defects are corrected and approved by the Engineer or accepted at a reduced price. Section 01455 allows for unacceptable materials to be accepted at a reduced price. (When a contract item does not meet contract requirements but is adequate to serve the design purpose,
the Engineer decides the extent to which the work will be accepted and remain in place. â&#x20AC;&#x201C; Section 00727)
For additional information refer to: UDOT Policy and Procedure 08B-31 Section 00727 Control of Work Removal of Unacceptable or Unauthorized Work Conformance with Plans and Specifications Section 01455 Materials Quality Requirements Unacceptable Materials FORM C106 INSTRUCTIONS RESIDENT ENGINEER/OFFICE When work or material does not meet contract requirements, notify the Contractor and District Engineer immediately. Form C106 is to be used for notifying the contractor of unacceptable work or material and ordered by the Resident Engineer to be removed and replaced, have deficiencies corrected, or accepted at a reduced price. Allowing unacceptable work or materials to remain in place requires the concurrence and approval of the Region Materials Engineer and District Engineer. Form C106 is not used for notification of disincentives, price adjustments, or pay factors applied in accordance with contract provisions. Complete the following Information: Contractor, Project Number, and Location. Complete the information in the table - listing the contract bid item number, description of the work or material and reason for rejection, quantity, and Resident Engineer directed action: to 1) remove and replace, 2) correct deficiencies, or 3) accept the indicated price reduction, if allowing the material to remain in place. IF ALLOWING MATERIAL TO REMAIN IN PLACE AT A REDUCED PRICE: OBTAIN CONCURRENCE FROM THE REGION MATERIALS ENGINEER AND DISTRICT ENGINEER BEFORE PREPARING AND SENDING FORM C106 TO THE CONTRACTOR. SIGNATURES ARE NOT REQUIRED BEFORE SENDING THE FORM TO THE CONTRACTOR. The Contractor has three working days from receipt of the C106 to either accept the directed action or request consideration and approval for an action different from that directed by the Resident Engineer. Failure to respond within three working days is considered Contractor acceptance of the action directed by the Resident Engineer. Upon receiving the returned form from the Contractor, or after the required time to respond has elapsed, obtain signatures of the District Engineer and Region Materials Engineer when applicable and file in the materials section of the project files. Send copies to the District Engineer and Region Materials Engineer and process the price reduction on the next partial estimate.
DISTRICT ENGINEER AND REGION MATERIALS ENGINEER Upon notification from the Resident Engineer of any reject work or material, review material requirements and information, recommend corrective action, and assist with determining price reduction if the material is going to be allowed to remain in place. Coordinate with the Resident Engineer, review and approve form C106 for any unacceptable work or material allowed to remain in place at a reduced price, when applicable.
Form xxx Rev 06/12
Project Number: Pin: Project Name: CONCRETE PLACEMENT LOG Key / Data Interpretation Y - No cylinders = Truck tested for air, slump and temp but cylinders not made Y - see above = same truck as line above but different item number or location VI = Visual Inspection *A reference number is the cylinder set that includes that placement; per MS&TR, sample 1/50 CY so some small placements are not sampled but are included in the set referenced **All placements must have at least one of the following: cylinder set, reference set, tests w/ no cylinders or VI (VI may also have reference set for 50 CY interval)
Visual Inpsection Qty to Date=
0 (Cannot Exceed 50 CY)
CONCRETE PLACEMENT / TESTING LOG Test Results Placement No
Placement Date
Contractor/ Sub
Concrete Source
Test / Cylinder Concrete Mix # ID #
Reference Cylinder ID#
Bid Item #
MP / Station From
MP / Station To
Offset
Qty Placed
Quantity To Date Ambient Temp
Water Added (Y/N)
Tested (Y/N)
Concrete Temp
Slump
Air Content
Sampled By
Tested By
Comment
28 day strength (psi)
28 day strength (psi)
28 day strength (psi)
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
12/30/2012
Avg 28 day strength #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1 of 2
Project Name Project Number PIN Foreign Steel and Iron tracking Date Current Contract Value = 0.1% of Current Contract Value= $
Item
Description
Location Offset
-
Unit Price from invoice w/ sales tax
Qty
Invoice Cost $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -
Total Value of Foreign Steel and Iron Material = $
12/30/2012
Comment
-
1 of 1
Construction Inspection Guide
Construction Closeout Forms
Form C-127 Revised 11/12
REGION CONTRACTS SPECIALISTS FINAL ESTIMATE PACKAGE CHECK LIST Project No.: Location:
ITEM
DESCRIPTION
FORM
1
Report on Assembly of Final Estimate
C128
2
Project Acceptance Report
C190
3
Project Materials Certification (Including Attachment A)
C196
4
Explanation of Overrun/Underrun
PDBS
5
Final Estimate (with signatures)
PDBS
6
DBE Item Analysis (Attach C.O. if applicable)
PDBS
7
Surety Consent Letter ((required upon 1.5% semi-final
estimate) or (required upon final estimate only if 1.5% semifinal estimate was not processed (i.e. Fast Track Projects)
Letter
8
Signature Sheet
C114
9
Contractor Performance Rating Report
C119
10
Post Construction Conference Report
C199
SUBMITTED
NOT REQUIRED
Progress Reports 11 12 13
14
15 16
(Signed copy (digital, scanned, etc.) for each month through final acceptance to be loaded into ProjectWise prior to processing the final packet)
Change Orders
(All forms complete with Signatures (digital, scanned, etc.)
Subcontract Agreements
(All forms complete with Signatures (digital, scanned, etc.)
Buy America Foreign Steel and Iron Tracking Form
(With cost documentation per Section 01455 (Federally-funded only)
OCIP Final Deduction Form
PDBS C100 + C115 Buy America Foreign Steel and Iron Form
(Email from Willis â&#x20AC;&#x201C; OCIP projects only)
Civil Rights Final Check List - FHWA 1273 As per 49 CFR. Part 26
Civil Rights Check List
Region Contracts Specialist
Date
Form C190 (10/12)
PROJECT ACCEPTANCE REPORT
(Reference Section 00570, UDOT Standard Specifications for Definitions)
Date: To (Prime
Contractorâ&#x20AC;&#x2122;s Name)
Project Number Location This is to advise you that a project inspection to verify Substantial Completion Physical Completion Contract Completion was performed on: Date
Inspection made by:
Resident Engineer/Field Engineer (Print)
In Accompaniment With: (Print) Name
Organization
The project is determined to be substantially complete. A Punch List is attached for work to be completed prior to the project reaching Physical Completion as defined by Specification 00570. The project is determined to be Physically Complete and has reached Final Acceptance. An itemized list is attached listing submittals and/or documentation required from you prior to the project attaining Contract Completion status as defined by Specification 00570. Items required for contract completion have been furnished and all Contractor obligations under the contract have been fulfilled.
Title
Date of Substantial Completion
Date of Physical Completion/Final Acceptance
Date of Contract Completion
Upon determination from the Project Inspection, the following work is required for Substantial Completion to be reached according to Specification 00570:
(Attach additional sheets if necessary)
Upon determination from the Project Inspection, the following work is required for Physical Completion to be reached according to Specification 00570:
(Attach additional sheets if necessary)
* (Refer to Section 00555 â&#x20AC;&#x201C; FAILURE TO COMPLETE ON TIME Including Schedule of Liquidated Damages) Resident Engineer
Date
Signature
District Engineer (required for Contract Completion only) Signature Cc:
Region Contract Specialist Region Material Engineer
Date
Form C196 (10/12)
PROJECT MATERIALS CERTIFICATION
PROJECT NO.: LOCATION: CONTRACTOR:
The results of the tests used in the acceptance program 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 specifications. * I further certify that all “Buy America” provisions in the above contract have been met.
Resident Engineer
Date
* Exceptions to the plans, specifications, and Quality Assurance Program are explained on C196 Attachment A.
Reviewed by:
District Engineer
**
Date
Exceptions to the plans, specifications, and Quality Assurance Program have been reviewed and coordinated with the Region Materials Engineer:
Region Materials Engineer
Date
**Note: Region Materials Engineer’s signature required only when exceptions are noted on C196 Attachment A
GENERAL INFORMATION Form C196 is the Department’s certification letter to FHWA required by 23CFR Part 637 – Construction Inspection and Approval. The C196 Attachment A is used to summarize and document exceptions to the approved plans, specifications, and the Department’s Quality Assurance Program in accordance with the requirements of 23CFR Part 637. An exception to the approved plans, specifications, and the Department’s Quality Assurance Program is defined as: 1) Unacceptable work or material allowed to remain in place at a reduced price. (Refer to form C106 instructions for additional information – Work or material with disincentives, price adjustments, or pay factors applied in accordance with approved contract provisions does not need to be reported on form C196 - Attachment A.) 2) Acceptance of work or material based upon an acceptance decision or determination contrary to the Department’s acceptance program or procedures outlined in the Minimum Sampling and Testing Requirements. Refer to UDOT Policy and Procedure 08B-31 for additional information. FORM C196 INSTRUCTIONS RESIDENT ENGINEER/OFFICE Upon Contract Completion, prepare form C196 by completing the following: Enter project number, description, and contractor information. List exceptions to the plans, specifications, and Quality Assurance Program on the C196 Attachment A, showing item number, material, quantity, basis for acceptance, and price reduction, if applicable. Exceptions require the concurrence of the District Engineer and Region Materials Engineer. Attach all documentation in support of any exceptions and the basis for acceptance decisions contrary to the Department’s acceptance program or established procedures. Attach copies of form(s) C106. Forward form C196 to the District Engineer for review and signature. DISTRICT ENGINEER Review form C196 and attachments to assure all required action has been completed. Forward form C196 to the Region Materials Engineer for review and signature when exceptions are noted on C196 Attachment A. Sign and forward form C196 to the Director of Construction and Materials with the final estimate and all original project records and source documentation. REGION MATERIALS ENGINEER Review form C196 and confirm that exceptions were coordinated as required. Sign and return to the District Engineer. (Signature is not required when there are no exceptions listed on C196 Attachment A.)
C196 A
(10/12)
C196 ATTACHMENT A (EXCEPTIONS TO THE APPROVED PLANS, SPECIFICATIONS, AND QUALITY ASSURANCE PROGRAM *)
ITEM NO.
Item Desc
WORK OR MATERIAL
QTY
BASIS FOR ACCEPTANCE
PRICE ADJUSTMENT
Soil / Aggregate
Concrete Aggregate
Roadway
Structures
Lighting, Signals, ATMS
Misc
1 of 1
1/2/2013
PROJECT FINAL PACKET CHECKLIST PIN No.:
Project No:
Form C-197 11/12
Project Name:
Prime Contractor: This form lists the documents required by UDOT before a project can be closed out. Place the items listed under Final Forms/Documentation in a separate folder and submit with the project files. Final Forms/Documentation – (PROJECTWISE) C-114 Signature Sheet C-119 Contractor Performance Report C-190 Project Acceptance Reports C-196 Project Material Certification & Attachment C-196A C-197 Final Estimate Check C-199 Post Construction Conference Report C-200 Certificate of Receipt and Release (One required for each private property Owner) Copy of Final Estimate Field Books (hard copy or electronic copy placed in ProjectWise) Project Diaries (hard copy or electronic copy placed in ProjectWise) OCIP Final Deduction (Email from Willis – OCIP projects only – Make sure OCIP deductions are entered in PDBS) Civil Rights Final Payment Checklist – (FHWA 1273 as per 49 CFR – Part 26) Survey Plat CD in Microstation Format (When Boundary Survey is required) – Distribute per Standard Specification 02896 As-Constructed Plans Original Weight Tickets Signed Progress Reports
Final Forms/Documentation – (PDBS) DBE Item Payment Analysis Project Ledger (Checked against Field Books or IPAQ/PDBS Entries) Explanation of Overruns/Under-Runs (attach Overrun/Under-Run Report) Prompt Payments (per Project Specifications)
Resident Engineer’s Project Documentation – (PROJECTWISE) RE Daily Diary (Printed and/or electronic copy) Complete Project Files with Final Forms/Documentation List of Field Book Numbers to Archive (Consultant Projects) As-Constructed Plans
PROJECT FINAL PACKET CHECKLIST
Form C-197 11/12
Project Files/Records – (PROJECTWISE) Preconstruction /Correspondence Notice of Award Notice to Proceed Preconstruction Conference Agenda, minutes and attendance roster Partnering Charter – Formal/Informal All Correspondence (incoming/outgoing) Request for Information (RFI) Public Information (Flyers/Log Book) Change Orders (Signed) (all) (Forms C-100, C-101, C-102, C-103, C-104, and C-107) R-5 – Transfer of Materials or Equipment Partial Estimates (Email Central Estimates & Agreements Specialist or submit by fax with a C-109 Fax Cover Sheet) Stockpile Material Invoices and Paid Invoices C-300 Fuel Cost Adjustments C-302 Asphalt Cost Adjustments
Project Reports – (PROJECTWISE) C-111 Project Daily Reports (CRE Files) (UDOT on IPAQ) C-114 Signature Sheet Signed Monthly Status of Contract Time (all – NTP through Contract Completion) CPM Schedule - Base Line and each update per Estimate Weekly Schedule/Progress/Partnering Meeting minutes C-120 Project Inspection Reports & FHWA Inspection Reports
Request to Sublet Work/Certified Payrolls C-115 (Signed) Subcontract Agreements (one original) (Federal Aid Projects Only) C-116 (Signed) Subcontract Agreement Certification (one original for each C-115 WH – 347 Certified Payrolls & Statement of Compliance (Federal Aid Projects Only)
PROJECT FINAL PACKET CHECKLIST
Form C-197 11/12
Materials – (PROJECTWISE) Note: All test reports and material acceptance information are to be maintained in the Resident Engineer’s office project files until Project Closeout and then turned in with the Final Paperwork. Establish files numerically by bid item number. Include all certifications, material test reports, approved shop drawings, etc. to support acceptance and payment. RCS DOES NOT CHECK FOR MATERIALS CERTIFICATION (S). THIS FUNCTION IS THE RESPONSIBILITY OF THE RESIDENT ENGINEER, THE REGION MATERIALS ENGINEER, AND THE DISTRICT ENGINEER. Suppliers List C-106 Notice of Unacceptable Work or Material C-196 Project Materials Certification C-196A Exceptions to Plans, Specifications or Material Acceptance Program Targets/Approved Mix Designs Central/Region Material Lab Reports Concrete Strength Reports Scale/Meter Certifications Weigh Tickets/Batch Tickets
Safety – (PROJECTWISE) Traffic Control Plan (RE must have indicated “Reviewed and Accepted” and Sign and Date) Daily Traffic Control Inspection Reports Traffic Control/Flagging Certifications Safety Inspections (UDOT Safety Officer) Contractor’s Claim Procedure (Reference Spec. 00820, not a written requirement, but Contractor should have provided one at RE’s request) OCIP (Owner Controlled Insurance Program) (Email for Willis)
Utility/Railroad/Cooperative Agreements – (PROJECTWISE) Signed Utility Change Orders Separate File for Each Entity Utility Agreements C-104 Daily/Weekly Record of Labor Materials, and Equipment Utility Billings C-193 Utility Fiscal Review Report C-193A Utility Fiscal Review Report
PROJECT FINAL PACKET CHECKLIST
Form C-197 11/12
Environmental Clearances/Permits/ - (PROJECTWISE) Environmental Clearances by the contractor for off-site work SWPPP (Storm Water Pollution Prevention Plan) ECS (Environmental Control Supervisor) Certifications Notice of Intent (NOI) for UPDES Permit (Storm Water General Permit for Construction Activities) Notice of Termination (NOT) for UPDES Permit – If disturbed areas do not meet final stabilization requirements, the UPDES Permit must be transferred to UDOT (Region District Engineer)
Civil Rights/Training – (PROJECTWISE) EEO and DBE Officers and Complaint Procedures DBE Commitment (PDBS) Training Commitment Form 100 Trainee Registrations (BAT/AGC) C-131 EEO Bulletin Board Review C-133 Harassment, Intimidation and Coercion Roster C-136 Labor & EEO Interviews of Workman on Utah Highway Projects C-141 Commercially Useful Function (CUF) Project Site Review (Required for all DBE’s) PR-1391 Yearly EEO Report (Required in Month of July Only) Safety Meeting Roster Form 1444 – Request for Authorization of Additional Classifications
Note: Some items may only apply to Federal Aid Projects. By signing below, the Resident Engineer indicates that all documentation/records have been checked against this Checklist and are included in this Package and are ready for submittal to the Region Contracts Specialist (RCS) for review. DO NOT SUBMIT PROJECT BOXES TO THE RCS FOR REVIEW IF ANY ITEMS LISTED ON THIS CHECKLIST ARE MISSING.
Resident Engineer Signature: Printed Name: Consultant Company Name (if applicable): Date:
C199 (6/09)
UTAH DEPARTMENT OF TRANSPORTATION POST CONSTRUCTION CONFERENCE REPORT
Project No.: Contractor:
Location: Project Engineer:
Conference Attendeeâ&#x20AC;&#x2122;s and Titles:
List Topics Discussed
Date:
Lessons Learned: (information entered here will be put in a central database)
Form C-200 (11/12)
CERTIFICATE OF RECEIPT AND RELEASE BY PROPERTY OWNER , Utah , 20___ It is certified by the undersigned: 1. ($
That receipt is acknowledged of the sum of ________________________________________ ) Dollars from
, the Utah Department of
Transportationâ&#x20AC;&#x2122;s Contractor, as payment in full for all materials taken or disturbance of property of the undersigned for use in the construction of Project No.
, designated as
in
County.
2.
The premises have been left in a satisfactory condition.
3.
This receipt releases Utah Department of Transportation from any further liability in connection with construction of the above described project.
Witness
Owner
Address Owner Address
Construction Inspection Guide
Tool Box Forms
DBE HOLD HARMLESS AGREEMENT This agreement, entered into this __________ day of ______, 20____, by and between ________________________________, hereinafter referred to as DBE (Disadvantaged Busing Enterprise Company) , ___________________________ , hereinafter referred to as PRIME CONTRACTOR, and the UTAH DEPARTMENT OF TRANSPORTATION, hereinafter referred to as UDOT. Whereas the DBE is unable to perform work listed in the below Statement of Work, or a change in the line item(s) the DBE was contracted to perform has occurred. Statement of work DBE contracted to perform: Project Number: ____________________ Line item(s), Description of work, Reason for not performing work and Amount: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ DBE agrees to protect, defend, indemnify and hold the PRIME CONTRACTOR, UDOT, and their employees, free and harmless from and against any and all losses, penalties, damages, settlements, costs, charges, professional fees, or other expenses or liabilities of every kind and character arising out of or relating to any and all claims in connection with or arising directly or indirectly out of this agreement and/or the non-performance of work listed in the above Statement of Work. DBE Company Official: ___________________________ (Print name) Signature ______________________________
Date ________________
OJT MONTHLY TRAINING SUMMARY CONTRACTOR:
DATE:
Period of Apprenticeship Mark # of Apprentice(s) in ea. Period
PROJECT NUMBER
NUMBER OF NUMBER OF TRAINING TRAINING % OF HOURS IN HOURS PROJECT CONTRACT COMPLETE COMPLETE
Prepared By: Job Title: Date:
NUMBER NUMBER OF NUMBER OF OF APPRENTICES MINORITY MINORITY REGISTERED FEMALES MALES
NUMBER OF NONMINORITY MALES
NUMBER OF NONMINORITY FEMALES
CLASSIFICATION
1
2 3 4 5 6 7 8 9 10
OJT SS MONTHLY REIMBURSEMENT FORM
Contractor
DATE:
Training Agency
Month Reporting ______________
Prepared By: Total
$0.00 Period of Apprenticeship
Name of Apprentice
Project Number
# of Days attended Class
# of Days worked on # of Children in a $ Amount for Federal Aid Child Care Daycare Project Reimbursment Program
$ Amount for Travel Reimbursment
M
F
Race Classification
1 2 3 4
5
6
7
8 9 10
Monthly Expense Report Month ____________ Year ______ . Training Program/ Institute ________________________________ ________
Number of Apprentices enrolled on this project _____. Name & Period _____________________________________________ Name & Period _____________________________________________ Name & Period _____________________________________________ Name & Period _____________________________________________
_______
Instructors cost for Class Room and on-the-job site:
_______
Material cost for books, CDâ&#x20AC;&#x2122;s and training aids:
_______
Secretary Costs:
_______
Equipment rental or purchases:
_______
Cost to maintain equipment:
Signature _____________________________________
12/30/2012;BAM Oe#3 afl-cio H: Word/Kris
Utah Department of Transportation 4501 South 2700 West - Box 141520 Salt Lake City, UT 84114 Phone: (801) 965-4740 Fax: (801) 965-4101
EEO/LABOR COMPLAINT FORM
*Note: Complaints must be filed within 180 days of the discriminatory action Your Name______________________________ Date of Filing__________________ Your Address_______________________________________________________________ Daytime Phone#:_____________
Evening or Cell Phone#: __________________
Name of Company you work for:__________________________________________ Federal Aid Highway project # on which the complaint is filed_________________ Project Location: _______________________________________________________ EEO Complaint - Indicate on what ground(s) you believe your were discriminated against: ________Race
________Color ________Nat. Origin
________Gender ________ Age
________Religion
________Handicap ________Other
What happened to you that you believe was discriminatory? Be specific, and complete as thoroughly as possible including date. Use additional sheets as necessary. Indicate the names of person(s) who are alleged to be responsible.
What Remedy? Requested Action? And/or adjustments are you requesting? Please be specific. Use additional sheets as necessary ______________________________________________________________________
LABOR Complaint â&#x20AC;&#x201C; Nature of complaint: _____ _____ _____ _____ _____
Underpayment of wages for work performed Underpayment of overtime for work performed Unauthorized payroll deduction Non-payment of fringe benefits Other (Please explain)
What happened to you that you believe you have a labor complaint? (Be specific and attach additional sheets if necessary)
Indicate the person(s) who are alleged to be responsible.
Names(s)
Work Performed
Current Classification (if known)
What remedy or adjustments are you requesting? Please be specific. Use additional sheets as necessary
Have you explained your EEO or Labor Complaint to your employer? _____ Yes or ______ No If so, whom did you talk to? Name: ________________________
Title: ________________________________
What was the outcome?__________________________________________________ Your Signature________________________________Date__________________________
(Name of Contractor) COMPLAINT PROCEDURE
Individuals desiring to submit a discrimination complaint are requested to follow the procedure below. If the employee feels for any reason they do not want to make contact with the person next listed or if that person is not available to register the complaint with, the employee should then feel free to contact the person listed next on the list. Informal discrimination complaints may be submitted verbally or in writing. Step 1: Contact your immediate supervisor. If you do not get satisfactory results at this level within a period of two (2) working days or desire to take the complaint further then, Step 2: Contact the project and/or Company EEO Officer, (List name of EEO Officer) (List phone number of EEO Officer) (List address of EEO Officer)
If you do not get satisfactory results with the company within a period of three (3) working days or desire to take the complaint further, then,
Step 3: Contact the UDOT Project Engineer or his EEO Representative at, (List name of Project Engineer and phone number, information should be current for each particular project.) OR,
Step 4: Contact one of the following Agencies: Utah Department of Transportation Civil Rights Office UDOT Complex 4501 South 2700 West Box 141520 Salt Lake City, Utah 84114-1520 Phone: (801) 965-4695 USDOL Antidiscrimination & Labor Division Labor Commission of Utah 160 East 300 South, 3rd Floor P. O. Box 146640 Salt Lake City, Utah 84114-6640 Phone: (801) 530-6801 or 1-800-222-1238 Federal Highway Administration 2520 West 4700 South Suite 9A Salt Lake City, Utah 84118-1880 Phone: (801) 963-0182
Utah Department of Transportation CIVIL RIGHTS DIVISION
Annual Training Program Reconciliation Report Training Agency Training Program Fiscal Year Contractor
Project Numbers
Hours Earned
Reimb. Amount
Amount Paid to Agency $ $ $ $ $ $ $
Training Costs: Instructors
Equipment Purchases Equipment Rental Maintain Equipment Materials Cost-book's,cd's,training aids ect.. Other
Total
$0.00
-
Submittal Log / Tracking Sheet Project Name Project Number PIN Bid Opening Date Submittal Log
Specification 1 01285 2 01315
Submittal ID
Filed in PW
3 01544
4 01721
5 02221 6 02221 7 02643
8 02842
Item Description Submittal Description Mobilization Public Information Services Name and contact information of PIC Logbook - updated and submitted weekly Contact database at end of project Fliers, emails, announcements, etc. prior to distribution Traffic Control Traffic Control Plan Positive Protection analysis (Std Dwg TC3B) Traffic Control Maintainer Certification Flagger Certifications Daily Traffic Control Inspections Daily Traffic Control Activity report Survey Survey control verification statement and field survey data Written description of equipment to be used including calibration certs, data storage methods, and manpower As-built plans Remove Guardrail Remove Asphalt Gutter Concrete Waterway Concrete mix design ( A(ae) minimum) Concrete hot / cold weather plan per 03055 Curing Compound product data, specs, and installation instructions Delineator Type 1
Est Qty
Units 1 LS 1 LS
Responsible Party
Date Reviewed / Returned
Review Time
Status
Re-submittal Date (if applicable)
Date Reviewed / Returned
Review Time
Status
0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0
0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0 0
0 0 0
0
0
Rebar and Delineator Manufacturer certificate of compliance
0
0
Penetrating concrete sealer manufacturer's product data, specifications, and installation instructions
0
0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
Letter confirming disposal location(s)
0
0
EEO and DBE Officers EEO Policy / Affirmative action plan DBE Commitment letter (get copy from PW) C133 - HIC Rosters Complaint Procedures (Prime and subs) Certified Payrolls in PDBS Prompt Payment in PDBS Fringe Benefit Programs PR-1391
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
Supplier List Surety consent letter for semi-final or final estimate
0 0
0 0
C115 / C116 Full copies of subcontracts as requested (minimum 1 per 10 subs)
0 0
0 0
Baseline schedule and narrative
0
0
CIP Concrete Constant Slope Barrier 54 Inch Buy America documentation
Concrete mix design ( AA(ae) minimum) Concrete hot / cold weather plan per 03055 Curing Compound product data, specs, and installation instructions
00727 & UDOT Safety and Health Manual
Date Received
Date Return Required By
0 0 0 0 1 LS
1 LS
4460 LF 2831 LF 68 LF
30 EA
Buy America documentation Manufacturer's product data or certificate of compliance
9 02844
Closed?
Item No.
CPM Activity ID
539 LF
Safety Name & contact information for Qualified Safety Person, Onsite safety person, and 24-hour contact information Copies of all weekly toolbox meetings JSAs pre-work and as required Hazard Communication Program and MSDS sheets for any hazardous material Employee orientation log Copies of weekly safety inspections Accidents or incidents reports Crane pick plans / JSAs Comprehensive Fall Protection Program Claim procedure Disposal Civil Rights
Other
Subcontracts
Schedule
12/30/2012
1 of 2
Project Number: Pin: Project Name: RFI Log
RFI No.
Date Initiated 1 5/10/2011 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16
Initiated By Contractor PM
RFI Description What is required delineator spacing?
Response Req'd By 5/17/2011
Responsible Party RE
Final Response See attached spreadsheet and reference standard drawing GW10
Date of Response 5/11/2011
Project Number: Pin: Project Name: Issues / Action Item Log
Item No.
Date Initiated
1 4/12/2012 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Description
Have state-furnished signal cabinets been ordered?
Responsible Party
John Doe
Date Resolution Req'd By
4/26/2012
Current Plan of Action
Date Resolved
John Doe to follow up with designer of record and state furnished materials 4/19/2012
Final Resolution Cabinets picked up today by Contractor "xx" and delivered to Region for testing. Ready to be installed at Contractor's discretion.
FHWA-1273 -- Revised May 1, 2012 REQUIRED CONTRACT PROVISIONS FEDERAL-AID CONSTRUCTION CONTRACTS
I. II. III. IV. V.
General Nondiscrimination Nonsegregated Facilities Davis-Bacon and Related Act Provisions Contract Work Hours and Safety Standards Act Provisions VI. Subletting or Assigning the Contract VII. Safety: Accident Prevention VIII. False Statements Concerning Highway Projects IX. Implementation of Clean Air Act and Federal Water Pollution Control Act X. Compliance with Governmentwide Suspension and Debarment Requirements XI. Certification Regarding Use of Contract Funds for Lobbying
3. A breach of any of the stipulations contained in these Required Contract Provisions may be sufficient grounds for withholding of progress payments, withholding of final payment, termination of the contract, suspension / debarment or any other action determined to be appropriate by the contracting agency and FHWA.
ATTACHMENTS
II. NONDISCRIMINATION
A. Employment and Materials Preference for Appalachian Development Highway System or Appalachian Local Access Road Contracts (included in Appalachian contracts only)
The provisions of this section related to 23 CFR Part 230 are applicable to all Federal-aid construction contracts and to all related construction subcontracts of $10,000 or more. The provisions of 23 CFR Part 230 are not applicable to material supply, engineering, or architectural service contracts.
4. Selection of Labor: During the performance of this contract, the contractor shall not use convict labor for any purpose within the limits of a construction project on a Federal-aid highway unless it is labor performed by convicts who are on parole, supervised release, or probation. The term Federal-aid highway does not include roadways functionally classified as local roads or rural minor collectors.
I. GENERAL In addition, the contractor and all subcontractors must comply with the following policies: Executive Order 11246, 41 CFR 60, 29 CFR 1625-1627, Title 23 USC Section 140, the Rehabilitation Act of 1973, as amended (29 USC 794), Title VI of the Civil Rights Act of 1964, as amended, and related regulations including 49 CFR Parts 21, 26 and 27; and 23 CFR Parts 200, 230, and 633.
1. Form FHWA-1273 must be physically incorporated in each construction contract funded under Title 23 (excluding emergency contracts solely intended for debris removal). The contractor (or subcontractor) must insert this form in each subcontract and further require its inclusion in all lower tier subcontracts (excluding purchase orders, rental agreements and other agreements for supplies or services).
The contractor and all subcontractors must comply with: the requirements of the Equal Opportunity Clause in 41 CFR 601.4(b) and, for all construction contracts exceeding $10,000, the Standard Federal Equal Employment Opportunity Construction Contract Specifications in 41 CFR 60-4.3.
The applicable requirements of Form FHWA-1273 are incorporated by reference for work done under any purchase order, rental agreement or agreement for other services. The prime contractor shall be responsible for compliance by any subcontractor, lower-tier subcontractor or service provider.
Note: The U.S. Department of Labor has exclusive authority to determine compliance with Executive Order 11246 and the policies of the Secretary of Labor including 41 CFR 60, and 29 CFR 1625-1627. The contracting agency and the FHWA have the authority and the responsibility to ensure compliance with Title 23 USC Section 140, the Rehabilitation Act of 1973, as amended (29 USC 794), and Title VI of the Civil Rights Act of 1964, as amended, and related regulations including 49 CFR Parts 21, 26 and 27; and 23 CFR Parts 200, 230, and 633.
Form FHWA-1273 must be included in all Federal-aid designbuild contracts, in all subcontracts and in lower tier subcontracts (excluding subcontracts for design services, purchase orders, rental agreements and other agreements for supplies or services). The design-builder shall be responsible for compliance by any subcontractor, lower-tier subcontractor or service provider. Contracting agencies may reference Form FHWA-1273 in bid proposal or request for proposal documents, however, the Form FHWA-1273 must be physically incorporated (not referenced) in all contracts, subcontracts and lower-tier subcontracts (excluding purchase orders, rental agreements and other agreements for supplies or services related to a construction contract).
The following provision is adopted from 23 CFR 230, Appendix A, with appropriate revisions to conform to the U.S. Department of Labor (US DOL) and FHWA requirements. 1. Equal Employment Opportunity: Equal employment opportunity (EEO) requirements not to discriminate and to take affirmative action to assure equal opportunity as set forth under laws, executive orders, rules, regulations (28 CFR 35, 29 CFR 1630, 29 CFR 1625-1627, 41 CFR 60 and 49 CFR 27) and orders of the Secretary of Labor as modified by the provisions prescribed herein, and imposed pursuant to 23 U.S.C. 140 shall constitute the EEO and specific affirmative action standards for the contractor's project activities under
2. Subject to the applicability criteria noted in the following sections, these contract provisions shall apply to all work performed on the contract by the contractor's own organization and with the assistance of workers under the contractor's immediate superintendence and to all work performed on the contract by piecework, station work, or by subcontract.
1
this contract. The provisions of the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.) set forth under 28 CFR 35 and 29 CFR 1630 are incorporated by reference in this contract. In the execution of this contract, the contractor agrees to comply with the following minimum specific requirement activities of EEO:
4. Recruitment: When advertising for employees, the contractor will include in all advertisements for employees the notation: "An Equal Opportunity Employer." All such advertisements will be placed in publications having a large circulation among minorities and women in the area from which the project work force would normally be derived.
a. The contractor will work with the contracting agency and the Federal Government to ensure that it has made every good faith effort to provide equal opportunity with respect to all of its terms and conditions of employment and in their review of activities under the contract.
a. The contractor will, unless precluded by a valid bargaining agreement, conduct systematic and direct recruitment through public and private employee referral sources likely to yield qualified minorities and women. To meet this requirement, the contractor will identify sources of potential minority group employees, and establish with such identified sources procedures whereby minority and women applicants may be referred to the contractor for employment consideration.
b. The contractor will accept as its operating policy the following statement: "It is the policy of this Company to assure that applicants are employed, and that employees are treated during employment, without regard to their race, religion, sex, color, national origin, age or disability. Such action shall include: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship, pre-apprenticeship, and/or on-thejob training."
b. In the event the contractor has a valid bargaining agreement providing for exclusive hiring hall referrals, the contractor is expected to observe the provisions of that agreement to the extent that the system meets the contractor's compliance with EEO contract provisions. Where implementation of such an agreement has the effect of discriminating against minorities or women, or obligates the contractor to do the same, such implementation violates Federal nondiscrimination provisions.
2. EEO Officer: The contractor will designate and make known to the contracting officers an EEO Officer who will have the responsibility for and must be capable of effectively administering and promoting an active EEO program and who must be assigned adequate authority and responsibility to do so.
c. The contractor will encourage its present employees to refer minorities and women as applicants for employment. Information and procedures with regard to referring such applicants will be discussed with employees. 5. Personnel Actions: Wages, working conditions, and employee benefits shall be established and administered, and personnel actions of every type, including hiring, upgrading, promotion, transfer, demotion, layoff, and termination, shall be taken without regard to race, color, religion, sex, national origin, age or disability. The following procedures shall be followed:
3. Dissemination of Policy: All members of the contractor's staff who are authorized to hire, supervise, promote, and discharge employees, or who recommend such action, or who are substantially involved in such action, will be made fully cognizant of, and will implement, the contractor's EEO policy and contractual responsibilities to provide EEO in each grade and classification of employment. To ensure that the above agreement will be met, the following actions will be taken as a minimum:
a. The contractor will conduct periodic inspections of project sites to insure that working conditions and employee facilities do not indicate discriminatory treatment of project site personnel.
a. Periodic meetings of supervisory and personnel office employees will be conducted before the start of work and then not less often than once every six months, at which time the contractor's EEO policy and its implementation will be reviewed and explained. The meetings will be conducted by the EEO Officer.
b. The contractor will periodically evaluate the spread of wages paid within each classification to determine any evidence of discriminatory wage practices. c. The contractor will periodically review selected personnel actions in depth to determine whether there is evidence of discrimination. Where evidence is found, the contractor will promptly take corrective action. If the review indicates that the discrimination may extend beyond the actions reviewed, such corrective action shall include all affected persons.
b. All new supervisory or personnel office employees will be given a thorough indoctrination by the EEO Officer, covering all major aspects of the contractor's EEO obligations within thirty days following their reporting for duty with the contractor. c. All personnel who are engaged in direct recruitment for the project will be instructed by the EEO Officer in the contractor's procedures for locating and hiring minorities and women.
d. The contractor will promptly investigate all complaints of alleged discrimination made to the contractor in connection with its obligations under this contract, will attempt to resolve such complaints, and will take appropriate corrective action within a reasonable time. If the investigation indicates that the discrimination may affect persons other than the complainant, such corrective action shall include such other persons. Upon completion of each investigation, the contractor will inform every complainant of all of their avenues of appeal.
d. Notices and posters setting forth the contractor's EEO policy will be placed in areas readily accessible to employees, applicants for employment and potential employees. e. The contractor's EEO policy and the procedures to implement such policy will be brought to the attention of employees by means of meetings, employee handbooks, or other appropriate means.
6. Training and Promotion: a. The contractor will assist in locating, qualifying, and increasing the skills of minorities and women who are
2
applicants for employment or current employees. Such efforts should be aimed at developing full journey level status employees in the type of trade or job classification involved.
with the requirements for and comply with the Americans with Disabilities Act and all rules and regulations established there under. Employers must provide reasonable accommodation in all employment activities unless to do so would cause an undue hardship.
b. Consistent with the contractor's work force requirements and as permissible under Federal and State regulations, the contractor shall make full use of training programs, i.e., apprenticeship, and on-the-job training programs for the geographical area of contract performance. In the event a special provision for training is provided under this contract, this subparagraph will be superseded as indicated in the special provision. The contracting agency may reserve training positions for persons who receive welfare assistance in accordance with 23 U.S.C. 140(a).
9. Selection of Subcontractors, Procurement of Materials and Leasing of Equipment: The contractor shall not discriminate on the grounds of race, color, religion, sex, national origin, age or disability in the selection and retention of subcontractors, including procurement of materials and leases of equipment. The contractor shall take all necessary and reasonable steps to ensure nondiscrimination in the administration of this contract.
c. The contractor will advise employees and applicants for employment of available training programs and entrance requirements for each.
a. The contractor shall notify all potential subcontractors and suppliers and lessors of their EEO obligations under this contract.
d. The contractor will periodically review the training and promotion potential of employees who are minorities and women and will encourage eligible employees to apply for such training and promotion.
b. The contractor will use good faith efforts to ensure subcontractor compliance with their EEO obligations. 10. Assurance Required by 49 CFR 26.13(b):
7. Unions: If the contractor relies in whole or in part upon unions as a source of employees, the contractor will use good faith efforts to obtain the cooperation of such unions to increase opportunities for minorities and women. Actions by the contractor, either directly or through a contractor's association acting as agent, will include the procedures set forth below:
a. The requirements of 49 CFR Part 26 and the State DOTâ&#x20AC;&#x2122;s U.S. DOT-approved DBE program are incorporated by reference. b. The contractor or subcontractor shall not discriminate on the basis of race, color, national origin, or sex in the performance of this contract. The contractor shall carry out applicable requirements of 49 CFR Part 26 in the award and administration of DOT-assisted contracts. Failure by the contractor to carry out these requirements is a material breach of this contract, which may result in the termination of this contract or such other remedy as the contracting agency deems appropriate.
a. The contractor will use good faith efforts to develop, in cooperation with the unions, joint training programs aimed toward qualifying more minorities and women for membership in the unions and increasing the skills of minorities and women so that they may qualify for higher paying employment. b. The contractor will use good faith efforts to incorporate an EEO clause into each union agreement to the end that such union will be contractually bound to refer applicants without regard to their race, color, religion, sex, national origin, age or disability.
11. Records and Reports: The contractor shall keep such records as necessary to document compliance with the EEO requirements. Such records shall be retained for a period of three years following the date of the final payment to the contractor for all contract work and shall be available at reasonable times and places for inspection by authorized representatives of the contracting agency and the FHWA.
c. The contractor is to obtain information as to the referral practices and policies of the labor union except that to the extent such information is within the exclusive possession of the labor union and such labor union refuses to furnish such information to the contractor, the contractor shall so certify to the contracting agency and shall set forth what efforts have been made to obtain such information.
a. The records kept by the contractor shall document the following: (1) The number and work hours of minority and nonminority group members and women employed in each work classification on the project;
d. In the event the union is unable to provide the contractor with a reasonable flow of referrals within the time limit set forth in the collective bargaining agreement, the contractor will, through independent recruitment efforts, fill the employment vacancies without regard to race, color, religion, sex, national origin, age or disability; making full efforts to obtain qualified and/or qualifiable minorities and women. The failure of a union to provide sufficient referrals (even though it is obligated to provide exclusive referrals under the terms of a collective bargaining agreement) does not relieve the contractor from the requirements of this paragraph. In the event the union referral practice prevents the contractor from meeting the obligations pursuant to Executive Order 11246, as amended, and these special provisions, such contractor shall immediately notify the contracting agency.
(2) The progress and efforts being made in cooperation with unions, when applicable, to increase employment opportunities for minorities and women; and (3) The progress and efforts being made in locating, hiring, training, qualifying, and upgrading minorities and women; b. The contractors and subcontractors will submit an annual report to the contracting agency each July for the duration of the project, indicating the number of minority, women, and non-minority group employees currently engaged in each work classification required by the contract work. This information is to be reported on Form FHWA-1391. The staffing data should represent the project work force on board in all or any part of the last payroll period preceding the end of July. If on-the-job training is being required by special provision, the contractor
8. Reasonable Accommodation for Applicants / Employees with Disabilities: The contractor must be familiar
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will be required to collect and report training data. The employment data should reflect the work force on board during all or any part of the last payroll period preceding the end of July.
of paragraph 1.d. of this section; also, regular contributions made or costs incurred for more than a weekly period (but not less often than quarterly) under plans, funds, or programs which cover the particular weekly period, are deemed to be constructively made or incurred during such weekly period. Such laborers and mechanics shall be paid the appropriate wage rate and fringe benefits on the wage determination for the classification of work actually performed, without regard to skill, except as provided in 29 CFR 5.5(a)(4). Laborers or mechanics performing work in more than one classification may be compensated at the rate specified for each classification for the time actually worked therein: Provided, That the employer's payroll records accurately set forth the time spent in each classification in which work is performed. The wage determination (including any additional classification and wage rates conformed under paragraph 1.b. of this section) and the Davis-Bacon poster (WHâ&#x20AC;&#x201C;1321) shall be posted at all times by the contractor and its subcontractors at the site of the work in a prominent and accessible place where it can be easily seen by the workers.
III. NONSEGREGATED FACILITIES This provision is applicable to all Federal-aid construction contracts and to all related construction subcontracts of $10,000 or more. The contractor must ensure that facilities provided for employees are provided in such a manner that segregation on the basis of race, color, religion, sex, or national origin cannot result. The contractor may neither require such segregated use by written or oral policies nor tolerate such use by employee custom. The contractor's obligation extends further to ensure that its employees are not assigned to perform their services at any location, under the contractor's control, where the facilities are segregated. The term "facilities" includes waiting rooms, work areas, restaurants and other eating areas, time clocks, restrooms, washrooms, locker rooms, and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing provided for employees. The contractor shall provide separate or single-user restrooms and necessary dressing or sleeping areas to assure privacy between sexes.
b. (1) The contracting officer shall require that any class of laborers or mechanics, including helpers, which is not listed in the wage determination and which is to be employed under the contract shall be classified in conformance with the wage determination. The contracting officer shall approve an additional classification and wage rate and fringe benefits therefore only when the following criteria have been met:
IV. DAVIS-BACON AND RELATED ACT PROVISIONS
(i) The work to be performed by the classification requested is not performed by a classification in the wage determination; and
This section is applicable to all Federal-aid construction projects exceeding $2,000 and to all related subcontracts and lower-tier subcontracts (regardless of subcontract size). The requirements apply to all projects located within the right-ofway of a roadway that is functionally classified as Federal-aid highway. This excludes roadways functionally classified as local roads or rural minor collectors, which are exempt. Contracting agencies may elect to apply these requirements to other projects.
(ii) The classification is utilized in the area by the construction industry; and (iii) The proposed wage rate, including any bona fide fringe benefits, bears a reasonable relationship to the wage rates contained in the wage determination. (2) If the contractor and the laborers and mechanics to be employed in the classification (if known), or their representatives, and the contracting officer agree on the classification and wage rate (including the amount designated for fringe benefits where appropriate), a report of the action taken shall be sent by the contracting officer to the Administrator of the Wage and Hour Division, Employment Standards Administration, U.S. Department of Labor, Washington, DC 20210. The Administrator, or an authorized representative, will approve, modify, or disapprove every additional classification action within 30 days of receipt and so advise the contracting officer or will notify the contracting officer within the 30-day period that additional time is necessary.
The following provisions are from the U.S. Department of Labor regulations in 29 CFR 5.5 â&#x20AC;&#x153;Contract provisions and related mattersâ&#x20AC;? with minor revisions to conform to the FHWA1273 format and FHWA program requirements. 1. Minimum wages a. All laborers and mechanics employed or working upon the site of the work, will be paid unconditionally and not less often than once a week, and without subsequent deduction or rebate on any account (except such payroll deductions as are permitted by regulations issued by the Secretary of Labor under the Copeland Act (29 CFR part 3)), the full amount of wages and bona fide fringe benefits (or cash equivalents thereof) due at time of payment computed at rates not less than those contained in the wage determination of the Secretary of Labor which is attached hereto and made a part hereof, regardless of any contractual relationship which may be alleged to exist between the contractor and such laborers and mechanics.
(3) In the event the contractor, the laborers or mechanics to be employed in the classification or their representatives, and the contracting officer do not agree on the proposed classification and wage rate (including the amount designated for fringe benefits, where appropriate), the contracting officer shall refer the questions, including the views of all interested parties and the recommendation of the contracting officer, to the Wage and Hour Administrator for determination. The Wage and Hour Administrator, or an authorized representative, will issue a determination within 30 days of receipt and so advise the contracting officer or
Contributions made or costs reasonably anticipated for bona fide fringe benefits under section 1(b)(2) of the Davis-Bacon Act on behalf of laborers or mechanics are considered wages paid to such laborers or mechanics, subject to the provisions
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will notify the contracting officer within the 30-day period that additional time is necessary.
Bacon Act, the contractor shall maintain records which show that the commitment to provide such benefits is enforceable, that the plan or program is financially responsible, and that the plan or program has been communicated in writing to the laborers or mechanics affected, and records which show the costs anticipated or the actual cost incurred in providing such benefits. Contractors employing apprentices or trainees under approved programs shall maintain written evidence of the registration of apprenticeship programs and certification of trainee programs, the registration of the apprentices and trainees, and the ratios and wage rates prescribed in the applicable programs.
(4) The wage rate (including fringe benefits where appropriate) determined pursuant to paragraphs 1.b.(2) or 1.b.(3) of this section, shall be paid to all workers performing work in the classification under this contract from the first day on which work is performed in the classification. c. Whenever the minimum wage rate prescribed in the contract for a class of laborers or mechanics includes a fringe benefit which is not expressed as an hourly rate, the contractor shall either pay the benefit as stated in the wage determination or shall pay another bona fide fringe benefit or an hourly cash equivalent thereof.
b. (1) The contractor shall submit weekly for each week in which any contract work is performed a copy of all payrolls to the contracting agency. The payrolls submitted shall set out accurately and completely all of the information required to be maintained under 29 CFR 5.5(a)(3)(i), except that full social security numbers and home addresses shall not be included on weekly transmittals. Instead the payrolls shall only need to include an individually identifying number for each employee ( e.g. , the last four digits of the employee's social security number). The required weekly payroll information may be submitted in any form desired. Optional Form WH–347 is available for this purpose from the Wage and Hour Division Web site at http://www.dol.gov/esa/whd/forms/wh347instr.htm or its successor site. The prime contractor is responsible for the submission of copies of payrolls by all subcontractors. Contractors and subcontractors shall maintain the full social security number and current address of each covered worker, and shall provide them upon request to the contracting agency for transmission to the State DOT, the FHWA or the Wage and Hour Division of the Department of Labor for purposes of an investigation or audit of compliance with prevailing wage requirements. It is not a violation of this section for a prime contractor to require a subcontractor to provide addresses and social security numbers to the prime contractor for its own records, without weekly submission to the contracting agency..
d. If the contractor does not make payments to a trustee or other third person, the contractor may consider as part of the wages of any laborer or mechanic the amount of any costs reasonably anticipated in providing bona fide fringe benefits under a plan or program, Provided, That the Secretary of Labor has found, upon the written request of the contractor, that the applicable standards of the Davis-Bacon Act have been met. The Secretary of Labor may require the contractor to set aside in a separate account assets for the meeting of obligations under the plan or program. 2. Withholding The contracting agency shall upon its own action or upon written request of an authorized representative of the Department of Labor, withhold or cause to be withheld from the contractor under this contract, or any other Federal contract with the same prime contractor, or any other federallyassisted contract subject to Davis-Bacon prevailing wage requirements, which is held by the same prime contractor, so much of the accrued payments or advances as may be considered necessary to pay laborers and mechanics, including apprentices, trainees, and helpers, employed by the contractor or any subcontractor the full amount of wages required by the contract. In the event of failure to pay any laborer or mechanic, including any apprentice, trainee, or helper, employed or working on the site of the work, all or part of the wages required by the contract, the contracting agency may, after written notice to the contractor, take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds until such violations have ceased.
(2) Each payroll submitted shall be accompanied by a “Statement of Compliance,” signed by the contractor or subcontractor or his or her agent who pays or supervises the payment of the persons employed under the contract and shall certify the following: (i) That the payroll for the payroll period contains the information required to be provided under §5.5 (a)(3)(ii) of Regulations, 29 CFR part 5, the appropriate information is being maintained under §5.5 (a)(3)(i) of Regulations, 29 CFR part 5, and that such information is correct and complete;
3. Payrolls and basic records
(ii) That each laborer or mechanic (including each helper, apprentice, and trainee) employed on the contract during the payroll period has been paid the full weekly wages earned, without rebate, either directly or indirectly, and that no deductions have been made either directly or indirectly from the full wages earned, other than permissible deductions as set forth in Regulations, 29 CFR part 3;
a. Payrolls and basic records relating thereto shall be maintained by the contractor during the course of the work and preserved for a period of three years thereafter for all laborers and mechanics working at the site of the work. Such records shall contain the name, address, and social security number of each such worker, his or her correct classification, hourly rates of wages paid (including rates of contributions or costs anticipated for bona fide fringe benefits or cash equivalents thereof of the types described in section 1(b)(2)(B) of the Davis-Bacon Act), daily and weekly number of hours worked, deductions made and actual wages paid. Whenever the Secretary of Labor has found under 29 CFR 5.5(a)(1)(iv) that the wages of any laborer or mechanic include the amount of any costs reasonably anticipated in providing benefits under a plan or program described in section 1(b)(2)(B) of the Davis-
(iii) That each laborer or mechanic has been paid not less than the applicable wage rates and fringe benefits or cash equivalents for the classification of work performed, as specified in the applicable wage determination incorporated into the contract.
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(3) The weekly submission of a properly executed certification set forth on the reverse side of Optional Form WHâ&#x20AC;&#x201C;347 shall satisfy the requirement for submission of the â&#x20AC;&#x153;Statement of Complianceâ&#x20AC;? required by paragraph 3.b.(2) of this section.
rate specified in the applicable wage determination. Apprentices shall be paid fringe benefits in accordance with the provisions of the apprenticeship program. If the apprenticeship program does not specify fringe benefits, apprentices must be paid the full amount of fringe benefits listed on the wage determination for the applicable classification. If the Administrator determines that a different practice prevails for the applicable apprentice classification, fringes shall be paid in accordance with that determination.
(4) The falsification of any of the above certifications may subject the contractor or subcontractor to civil or criminal prosecution under section 1001 of title 18 and section 231 of title 31 of the United States Code.
In the event the Office of Apprenticeship Training, Employer and Labor Services, or a State Apprenticeship Agency recognized by the Office, withdraws approval of an apprenticeship program, the contractor will no longer be permitted to utilize apprentices at less than the applicable predetermined rate for the work performed until an acceptable program is approved.
c. The contractor or subcontractor shall make the records required under paragraph 3.a. of this section available for inspection, copying, or transcription by authorized representatives of the contracting agency, the State DOT, the FHWA, or the Department of Labor, and shall permit such representatives to interview employees during working hours on the job. If the contractor or subcontractor fails to submit the required records or to make them available, the FHWA may, after written notice to the contractor, the contracting agency or the State DOT, take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds. Furthermore, failure to submit the required records upon request or to make such records available may be grounds for debarment action pursuant to 29 CFR 5.12.
b. Trainees (programs of the USDOL). Except as provided in 29 CFR 5.16, trainees will not be permitted to work at less than the predetermined rate for the work performed unless they are employed pursuant to and individually registered in a program which has received prior approval, evidenced by formal certification by the U.S. Department of Labor, Employment and Training Administration.
4. Apprentices and trainees a. Apprentices (programs of the USDOL).
The ratio of trainees to journeymen on the job site shall not be greater than permitted under the plan approved by the Employment and Training Administration.
Apprentices will be permitted to work at less than the predetermined rate for the work they performed when they are employed pursuant to and individually registered in a bona fide apprenticeship program registered with the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship Training, Employer and Labor Services, or with a State Apprenticeship Agency recognized by the Office, or if a person is employed in his or her first 90 days of probationary employment as an apprentice in such an apprenticeship program, who is not individually registered in the program, but who has been certified by the Office of Apprenticeship Training, Employer and Labor Services or a State Apprenticeship Agency (where appropriate) to be eligible for probationary employment as an apprentice.
Every trainee must be paid at not less than the rate specified in the approved program for the trainee's level of progress, expressed as a percentage of the journeyman hourly rate specified in the applicable wage determination. Trainees shall be paid fringe benefits in accordance with the provisions of the trainee program. If the trainee program does not mention fringe benefits, trainees shall be paid the full amount of fringe benefits listed on the wage determination unless the Administrator of the Wage and Hour Division determines that there is an apprenticeship program associated with the corresponding journeyman wage rate on the wage determination which provides for less than full fringe benefits for apprentices. Any employee listed on the payroll at a trainee rate who is not registered and participating in a training plan approved by the Employment and Training Administration shall be paid not less than the applicable wage rate on the wage determination for the classification of work actually performed. In addition, any trainee performing work on the job site in excess of the ratio permitted under the registered program shall be paid not less than the applicable wage rate on the wage determination for the work actually performed.
The allowable ratio of apprentices to journeymen on the job site in any craft classification shall not be greater than the ratio permitted to the contractor as to the entire work force under the registered program. Any worker listed on a payroll at an apprentice wage rate, who is not registered or otherwise employed as stated above, shall be paid not less than the applicable wage rate on the wage determination for the classification of work actually performed. In addition, any apprentice performing work on the job site in excess of the ratio permitted under the registered program shall be paid not less than the applicable wage rate on the wage determination for the work actually performed. Where a contractor is performing construction on a project in a locality other than that in which its program is registered, the ratios and wage rates (expressed in percentages of the journeyman's hourly rate) specified in the contractor's or subcontractor's registered program shall be observed.
In the event the Employment and Training Administration withdraws approval of a training program, the contractor will no longer be permitted to utilize trainees at less than the applicable predetermined rate for the work performed until an acceptable program is approved. c. Equal employment opportunity. The utilization of apprentices, trainees and journeymen under this part shall be in conformity with the equal employment opportunity requirements of Executive Order 11246, as amended, and 29 CFR part 30.
Every apprentice must be paid at not less than the rate specified in the registered program for the apprentice's level of progress, expressed as a percentage of the journeymen hourly
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d. Apprentices and Trainees (programs of the U.S. DOT). V. CONTRACT WORK HOURS AND SAFETY STANDARDS ACT
Apprentices and trainees working under apprenticeship and skill training programs which have been certified by the Secretary of Transportation as promoting EEO in connection with Federal-aid highway construction programs are not subject to the requirements of paragraph 4 of this Section IV. The straight time hourly wage rates for apprentices and trainees under such programs will be established by the particular programs. The ratio of apprentices and trainees to journeymen shall not be greater than permitted by the terms of the particular program.
The following clauses apply to any Federal-aid construction contract in an amount in excess of $100,000 and subject to the overtime provisions of the Contract Work Hours and Safety Standards Act. These clauses shall be inserted in addition to the clauses required by 29 CFR 5.5(a) or 29 CFR 4.6. As used in this paragraph, the terms laborers and mechanics include watchmen and guards.
5. Compliance with Copeland Act requirements. The contractor shall comply with the requirements of 29 CFR part 3, which are incorporated by reference in this contract.
1. Overtime requirements. No contractor or subcontractor contracting for any part of the contract work which may require or involve the employment of laborers or mechanics shall require or permit any such laborer or mechanic in any workweek in which he or she is employed on such work to work in excess of forty hours in such workweek unless such laborer or mechanic receives compensation at a rate not less than one and one-half times the basic rate of pay for all hours worked in excess of forty hours in such workweek.
6. Subcontracts. The contractor or subcontractor shall insert Form FHWA-1273 in any subcontracts and also require the subcontractors to include Form FHWA-1273 in any lower tier subcontracts. The prime contractor shall be responsible for the compliance by any subcontractor or lower tier subcontractor with all the contract clauses in 29 CFR 5.5.
2. Violation; liability for unpaid wages; liquidated damages. In the event of any violation of the clause set forth in paragraph (1.) of this section, the contractor and any subcontractor responsible therefor shall be liable for the unpaid wages. In addition, such contractor and subcontractor shall be liable to the United States (in the case of work done under contract for the District of Columbia or a territory, to such District or to such territory), for liquidated damages. Such liquidated damages shall be computed with respect to each individual laborer or mechanic, including watchmen and guards, employed in violation of the clause set forth in paragraph (1.) of this section, in the sum of $10 for each calendar day on which such individual was required or permitted to work in excess of the standard workweek of forty hours without payment of the overtime wages required by the clause set forth in paragraph (1.) of this section.
7. Contract termination: debarment. A breach of the contract clauses in 29 CFR 5.5 may be grounds for termination of the contract, and for debarment as a contractor and a subcontractor as provided in 29 CFR 5.12. 8. Compliance with Davis-Bacon and Related Act requirements. All rulings and interpretations of the DavisBacon and Related Acts contained in 29 CFR parts 1, 3, and 5 are herein incorporated by reference in this contract. 9. Disputes concerning labor standards. Disputes arising out of the labor standards provisions of this contract shall not be subject to the general disputes clause of this contract. Such disputes shall be resolved in accordance with the procedures of the Department of Labor set forth in 29 CFR parts 5, 6, and 7. Disputes within the meaning of this clause include disputes between the contractor (or any of its subcontractors) and the contracting agency, the U.S. Department of Labor, or the employees or their representatives.
3. Withholding for unpaid wages and liquidated damages. The FHWA or the contacting agency shall upon its own action or upon written request of an authorized representative of the Department of Labor withhold or cause to be withheld, from any moneys payable on account of work performed by the contractor or subcontractor under any such contract or any other Federal contract with the same prime contractor, or any other federally-assisted contract subject to the Contract Work Hours and Safety Standards Act, which is held by the same prime contractor, such sums as may be determined to be necessary to satisfy any liabilities of such contractor or subcontractor for unpaid wages and liquidated damages as provided in the clause set forth in paragraph (2.) of this section.
10. Certification of eligibility. a. By entering into this contract, the contractor certifies that neither it (nor he or she) nor any person or firm who has an interest in the contractor's firm is a person or firm ineligible to be awarded Government contracts by virtue of section 3(a) of the Davis-Bacon Act or 29 CFR 5.12(a)(1). b. No part of this contract shall be subcontracted to any person or firm ineligible for award of a Government contract by virtue of section 3(a) of the Davis-Bacon Act or 29 CFR 5.12(a)(1).
4. Subcontracts. The contractor or subcontractor shall insert in any subcontracts the clauses set forth in paragraph (1.) through (4.) of this section and also a clause requiring the subcontractors to include these clauses in any lower tier subcontracts. The prime contractor shall be responsible for compliance by any subcontractor or lower tier subcontractor with the clauses set forth in paragraphs (1.) through (4.) of this section.
c. The penalty for making false statements is prescribed in the U.S. Criminal Code, 18 U.S.C. 1001.
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evidenced in writing and that it contains all pertinent provisions and requirements of the prime contract.
VI. SUBLETTING OR ASSIGNING THE CONTRACT This provision is applicable to all Federal-aid construction contracts on the National Highway System.
5. The 30% self-performance requirement of paragraph (1) is not applicable to design-build contracts; however, contracting agencies may establish their own self-performance requirements.
1. The contractor shall perform with its own organization contract work amounting to not less than 30 percent (or a greater percentage if specified elsewhere in the contract) of the total original contract price, excluding any specialty items designated by the contracting agency. Specialty items may be performed by subcontract and the amount of any such specialty items performed may be deducted from the total original contract price before computing the amount of work required to be performed by the contractor's own organization (23 CFR 635.116).
VII. SAFETY: ACCIDENT PREVENTION T h i s p r o v i s i o n i s applicable to all Federal-aid construction contracts and to all related subcontracts. 1. In the performance of this contract the contractor shall comply with all applicable Federal, State, and local laws governing safety, health, and sanitation (23 CFR 635). The contractor shall provide all safeguards, safety devices and protective equipment and take any other needed actions as it determines, or as the contracting officer may determine, to be reasonably necessary to protect the life and health of employees on the job and the safety of the public and to protect property in connection with the performance of the work covered by the contract.
a. The term â&#x20AC;&#x153;perform work with its own organizationâ&#x20AC;? refers to workers employed or leased by the prime contractor, and equipment owned or rented by the prime contractor, with or without operators. Such term does not include employees or equipment of a subcontractor or lower tier subcontractor, agents of the prime contractor, or any other assignees. The term may include payments for the costs of hiring leased employees from an employee leasing firm meeting all relevant Federal and State regulatory requirements. Leased employees may only be included in this term if the prime contractor meets all of the following conditions:
2. It is a condition of this contract, and shall be made a condition of each subcontract, which the contractor enters into pursuant to this contract, that the contractor and any subcontractor shall not permit any employee, in performance of the contract, to work in surroundings or under conditions which are unsanitary, hazardous or dangerous to his/her health or safety, as determined under construction safety and health standards (29 CFR 1926) promulgated by the Secretary of Labor, in accordance with Section 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C. 3704).
(1) the prime contractor maintains control over the supervision of the day-to-day activities of the leased employees; (2) the prime contractor remains responsible for the quality of the work of the leased employees; (3) the prime contractor retains all power to accept or exclude individual employees from work on the project; and (4) the prime contractor remains ultimately responsible for the payment of predetermined minimum wages, the submission of payrolls, statements of compliance and all other Federal regulatory requirements.
3. Pursuant to 29 CFR 1926.3, it is a condition of this contract that the Secretary of Labor or authorized representative thereof, shall have right of entry to any site of contract performance to inspect or investigate the matter of compliance with the construction safety and health standards and to carry out the duties of the Secretary under Section 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C.3704).
b. "Specialty Items" shall be construed to be limited to work that requires highly specialized knowledge, abilities, or equipment not ordinarily available in the type of contracting organizations qualified and expected to bid or propose on the contract as a whole and in general are to be limited to minor components of the overall contract.
VIII. FALSE STATEMENTS CONCERNING HIGHWAY PROJECTS
2. The contract amount upon which the requirements set forth in paragraph (1) of Section VI is computed includes the cost of material and manufactured products which are to be purchased or produced by the contractor under the contract provisions.
T h i s p r o v i s i o n i s applicable to all Federal-aid construction contracts and to all related subcontracts. In order to assure high quality and durable construction in conformity with approved plans and specifications and a high degree of reliability on statements and representations made by engineers, contractors, suppliers, and workers on Federalaid highway projects, it is essential that all persons concerned with the project perform their functions as carefully, thoroughly, and honestly as possible. Willful falsification, distortion, or misrepresentation with respect to any facts related to the project is a violation of Federal law. To prevent any misunderstanding regarding the seriousness of these and similar acts, Form FHWA-1022 shall be posted on each Federal-aid highway project (23 CFR 635) in one or more places where it is readily available to all persons concerned with the project:
3. The contractor shall furnish (a) a competent superintendent or supervisor who is employed by the firm, has full authority to direct performance of the work in accordance with the contract requirements, and is in charge of all construction operations (regardless of who performs the work) and (b) such other of its own organizational resources (supervision, management, and engineering services) as the contracting officer determines is necessary to assure the performance of the contract. 4. No portion of the contract shall be sublet, assigned or otherwise disposed of except with the written consent of the contracting officer, or authorized representative, and such consent when given shall not be construed to relieve the contractor of any responsibility for the fulfillment of the contract. Written consent will be given only after the contracting agency has assured that each subcontract is
18 U.S.C. 1020 reads as follows:
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"Whoever, being an officer, agent, or employee of the United States, or of any State or Territory, or whoever, whether a person, association, firm, or corporation, knowingly makes any false statement, false representation, or false report as to the character, quality, quantity, or cost of the material used or to be used, or the quantity or quality of the work performed or to be performed, or the cost thereof in connection with the submission of plans, maps, specifications, contracts, or costs of construction on any highway or related project submitted for approval to the Secretary of Transportation; or
covered transaction. The prospective first tier participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective first tier participant to furnish a certification or an explanation shall disqualify such a person from participation in this transaction. c. The certification in this clause is a material representation of fact upon which reliance was placed when the contracting agency determined to enter into this transaction. If it is later determined that the prospective participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the contracting agency may terminate this transaction for cause of default.
Whoever knowingly makes any false statement, false representation, false report or false claim with respect to the character, quality, quantity, or cost of any work performed or to be performed, or materials furnished or to be furnished, in connection with the construction of any highway or related project approved by the Secretary of Transportation; or
d. The prospective first tier participant shall provide immediate written notice to the contracting agency to whom this proposal is submitted if any time the prospective first tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
Whoever knowingly makes any false statement or false representation as to material fact in any statement, certificate, or report submitted pursuant to provisions of the Federal-aid Roads Act approved July 1, 1916, (39 Stat. 355), as amended and supplemented; Shall be fined under this title or imprisoned not more than 5 years or both."
e. The terms "covered transaction," "debarred," "suspended," "ineligible," "participant," "person," "principal," and "voluntarily excluded," as used in this clause, are defined in 2 CFR Parts 180 and 1200. “First Tier Covered Transactions” refers to any covered transaction between a grantee or subgrantee of Federal funds and a participant (such as the prime or general contract). “Lower Tier Covered Transactions” refers to any covered transaction under a First Tier Covered Transaction (such as subcontracts). “First Tier Participant” refers to the participant who has entered into a covered transaction with a grantee or subgrantee of Federal funds (such as the prime or general contractor). “Lower Tier Participant” refers any participant who has entered into a covered transaction with a First Tier Participant or other Lower Tier Participants (such as subcontractors and suppliers).
IX. IMPLEMENTATION OF CLEAN AIR ACT AND FEDERAL WATER POLLUTION CONTROL ACT This provision is applicable to all Federal-aid construction contracts and to all related subcontracts. By submission of this bid/proposal or the execution of this contract, or subcontract, as appropriate, the bidder, proposer, Federal-aid construction contractor, or subcontractor, as appropriate, will be deemed to have stipulated as follows: 1. That any person who is or will be utilized in the performance of this contract is not prohibited from receiving an award due to a violation of Section 508 of the Clean Water Act or Section 306 of the Clean Air Act. 2. That the contractor agrees to include or cause to be included the requirements of paragraph (1) of this Section X in every subcontract, and further agrees to take such action as the contracting agency may direct as a means of enforcing such requirements.
f. The prospective first tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction. g. The prospective first tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions," provided by the department or contracting agency, entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions exceeding the $25,000 threshold.
X. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION This provision is applicable to all Federal-aid construction contracts, design-build contracts, subcontracts, lower-tier subcontracts, purchase orders, lease agreements, consultant contracts or any other covered transaction requiring FHWA approval or that is estimated to cost $25,000 or more – as defined in 2 CFR Parts 180 and 1200.
h. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant is responsible for ensuring that its principals are not suspended, debarred, or otherwise ineligible to participate in covered transactions. To verify the eligibility of its principals, as well as the eligibility of any lower tier prospective participants, each participant may, but is not required to, check the Excluded Parties List System website (https://www.epls.gov/), which is compiled by the General Services Administration.
1. Instructions for Certification – First Tier Participants: a. By signing and submitting this proposal, the prospective first tier participant is providing the certification set out below. b. The inability of a person to provide the certification set out below will not necessarily result in denial of participation in this
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i. Nothing contained in the foregoing shall be construed to require the establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of the prospective participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
this transaction originated may pursue available remedies, including suspension and/or debarment. c. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous by reason of changed circumstances.
j. Except for transactions authorized under paragraph (f) of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.
d. The terms "covered transaction," "debarred," "suspended," "ineligible," "participant," "person," "principal," and "voluntarily excluded," as used in this clause, are defined in 2 CFR Parts 180 and 1200. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. “First Tier Covered Transactions” refers to any covered transaction between a grantee or subgrantee of Federal funds and a participant (such as the prime or general contract). “Lower Tier Covered Transactions” refers to any covered transaction under a First Tier Covered Transaction (such as subcontracts). “First Tier Participant” refers to the participant who has entered into a covered transaction with a grantee or subgrantee of Federal funds (such as the prime or general contractor). “Lower Tier Participant” refers any participant who has entered into a covered transaction with a First Tier Participant or other Lower Tier Participants (such as subcontractors and suppliers).
***** 2. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – First Tier Participants: a. The prospective first tier participant certifies to the best of its knowledge and belief, that it and its principals: (1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in covered transactions by any Federal department or agency;
e. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.
(2) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
f. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions exceeding the $25,000 threshold.
(3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (a)(2) of this certification; and
g. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant is responsible for ensuring that its principals are not suspended, debarred, or otherwise ineligible to participate in covered transactions. To verify the eligibility of its principals, as well as the eligibility of any lower tier prospective participants, each participant may, but is not required to, check the Excluded Parties List System website (https://www.epls.gov/), which is compiled by the General Services Administration.
(4) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. b. Where the prospective participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. 2. Instructions for Certification - Lower Tier Participants: (Applicable to all subcontracts, purchase orders and other lower tier transactions requiring prior FHWA approval or estimated to cost $25,000 or more - 2 CFR Parts 180 and 1200)
h. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
a. By signing and submitting this proposal, the prospective lower tier is providing the certification set out below. b. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department, or agency with which
i. Except for transactions authorized under paragraph e of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the
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department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. ***** Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Participants: 1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in covered transactions by any Federal department or agency. 2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. ***** XI. CERTIFICATION REGARDING USE OF CONTRACT FUNDS FOR LOBBYING This provision is applicable to all Federal-aid construction contracts and to all related subcontracts which exceed $100,000 (49 CFR 20). 1. The prospective participant certifies, by signing and submitting this bid or proposal, to the best of his or her knowledge and belief, that: a. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. b. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. 2. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 3. The prospective participant also agrees by submitting its bid or proposal that the participant shall require that the language of this certification be included in all lower tier subcontracts, which exceed $100,000 and that all such recipients shall certify and disclose accordingly.
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ATTACHMENT A - EMPLOYMENT AND MATERIALS PREFERENCE FOR APPALACHIAN DEVELOPMENT HIGHWAY SYSTEM OR APPALACHIAN LOCAL ACCESS ROAD CONTRACTS This provision is applicable to all Federal-aid projects funded under the Appalachian Regional Development Act of 1965.
6. The contractor shall include the provisions of Sections 1 through 4 of this Attachment A in every subcontract for work which is, or reasonably may be, done as on-site work.
1. During the performance of this contract, the contractor undertaking to do work which is, or reasonably may be, done as on-site work, shall give preference to qualified persons who regularly reside in the labor area as designated by the DOL wherein the contract work is situated, or the subregion, or the Appalachian counties of the State wherein the contract work is situated, except: a. To the extent that qualified persons regularly residing in the area are not available. b. For the reasonable needs of the contractor to employ supervisory or specially experienced personnel necessary to assure an efficient execution of the contract work. c. For the obligation of the contractor to offer employment to present or former employees as the result of a lawful collective bargaining contract, provided that the number of nonresident persons employed under this subparagraph (1c) shall not exceed 20 percent of the total number of employees employed by the contractor on the contract work, except as provided in subparagraph (4) below. 2. The contractor shall place a job order with the State Employment Service indicating (a) the classifications of the laborers, mechanics and other employees required to perform the contract work, (b) the number of employees required in each classification, (c) the date on which the participant estimates such employees will be required, and (d) any other pertinent information required by the State Employment Service to complete the job order form. The job order may be placed with the State Employment Service in writing or by telephone. If during the course of the contract work, the information submitted by the contractor in the original job order is substantially modified, the participant shall promptly notify the State Employment Service. 3. The contractor shall give full consideration to all qualified job applicants referred to him by the State Employment Service. The contractor is not required to grant employment to any job applicants who, in his opinion, are not qualified to perform the classification of work required. 4. If, within one week following the placing of a job order by the contractor with the State Employment Service, the State Employment Service is unable to refer any qualified job applicants to the contractor, or less than the number requested, the State Employment Service will forward a certificate to the contractor indicating the unavailability of applicants. Such certificate shall be made a part of the contractor's permanent project records. Upon receipt of this certificate, the contractor may employ persons who do not normally reside in the labor area to fill positions covered by the certificate, notwithstanding the provisions of subparagraph (1c) above. 5. The provisions of 23 CFR 633.207(e) allow the contracting agency to provide a contractual preference for the use of mineral resource materials native to the Appalachian region.
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Construction Inspection Guide Chapter Links
1-Preface & Introduction
2-Traffic Control
3-Demolition and Earthwork
4-Drainage
5-Pavement & Materials
6-Structures
7-Traffic Signals, Lighting, ATMS
8-Striping, Signing, Safety Features
9-Landscaping, Fencing, Incidental Const.
10-Utilities
11-PDBS
12-Crash Cushion & Barrier End Treatments
Appendix : Construction Forms
Construction Inspection Guide
udot.utah.gov/go/construction