APPENDIX A BLANK FORMS Appendix A.01.1 - Pre-Construction ...

APPENDIX A – BLANK FORMS Appendix A.01.1 - Pre-Construction Conference Agenda Template

Appendix A.02.1 (F.10.2) - Weekly Meeting Agenda Template

Appendix A.03.1 - Construction Weekly Summary Report

Appendix A.04.1 - MCDOT Daily Project Diary Form (Work & Quantity Documentation)

Appendix A.05.1 - Daily Recap of Off-Duty Officer and Vehicle Use

Appendix A.06.1 - Submittal Tracking Log

Appendix A.07.1 - RFI Tracking Log

Appendix A.08.1 (F.14.3) - Materials Certificate Checklist

Appendix A.08.2 - Materials Certificate Log

Appendix A.09.1 - Punch List Log

Appendix A.10.1 - Actual Cost Work (T&M) Worksheet

Appendix A.10.2 (F.09.8) - MCDOT Subcontractor Request Form (SRF)

Appendix A.10.3 (F.09.9) - Subcontract Approval Checklist

Appendix A.10.4 (F.12.1) - Subcontractor Log

Appendix A.11.1 (F.12.2) - MCDOT Sign Salvage Manifest Form

Maricopa County Department of Transportation

Preconstruction Conference

AGENDA

Insert Contractor Logo

Enter Project Name

Enter Project #

Enter Date

Page 1 of 4 3/23/2017

1. Self-Introductions of Attendees – sign in on Attendance Sheet

2. Project Introduction:

• Location:

3. MCDOT Representatives

• Construction Manager

• Inspector

• Design Project Manager

• Traffic Control

• PIO

• Survey

• Materials Testing QA

• Environmental

• Signing

• Right-of-Way

• Utilities

4. Contractor Representatives –

• Project Manager

• Superintendent

5. Communications and Coordination

• The Contractor is reminded that the Construction Manager (CM) has immediate charge of the

administrative and engineering details of the project. The Contractor is cautioned that only the CM and

Inspector are authorized to provide information, clarification, or interpretation regarding plans,

specifications, and any other contract documents or requirements. Solicitation and receipt of

information by the Contractor from any other MCDOT representative will not be considered valid for

administration of the project. Shop drawings and all other submittals required by the Contract shall be

submitted to the CM. Submittals made to and received by other MCDOT representatives will not be

considered valid for the purpose of administration of the Contract.

• All Mail, Submittals and Request for Information (RFI) for MCDOT shall be sent to Enter CM Name.

CM will forward documentation to the appropriate MCDOT staff for review and approval.

• All Mail, Submittals and Request for Information (RFI) for Enter Contractors Name shall be sent to

Enter Contractors PM Name.

• Daily field scheduling, coordination and field issues shall be discussed and coordinated between the

MCDOT Inspector and Contractors Field Representative.

Page 2 of 4 3/23/2017

• Field changes such as modifications and monetary expenses shall be submitted in writing and discussed

with the CM.

• Try to resolve all issues at the lowest level.

6. Title VI

• Kimberly Richards is the Intergovernmental Coordinator for this project 602-506-1630

• Presentation on Title VI

• Keep copy of Title VI Presentation on project site.

7. Public Relations

• Enter PIO Rep Name & Phone # is the Public Information Officer for this project.

• Complaint Handling – Follow up and resolve promptly. Keep records of complaints and actions.

• MCDOT Project Information 602-506-3342

• Contractor to notify emergency services, schools, mail carrier and trash services of project.

8. Environmental

• To prevent the introduction of invasive species, all construction equipment shall be washed prior to

entering and leaving the construction site.

• Environmental Clearance and attachments – review and keep on the project site during working

operations.

• NESHAP Asbestos Survey – keep on project site during working operations.

• Bird Nesting Survey

• Storm Water Pollution Prevention Plan (SWPPP)

9. Right-of-Way

• The contractor shall keep the construction operations within the existing ROW and Easement.

• Marshaling Yard / Staging Area.

• Agreements to Access Private Property

• Contractor shall furnish the MCDOT CM properly executed written documentation from

property owners that authorizes the Contractor the use private property for marshalling yard or

staging area.

10. Utilities

• Contractor is reminded that they are responsible to request Arizona 811 (BlueStake), verify and locate

existing utilities. Submit Arizona 811 confirmation to Inspector.

11. Survey

• Survey will be provided by MCDOT

• Survey requests are to be made electronically through Enter Inspectors Name

• Provide reasonable and specific survey requests.

• Two full working days advance notice is required for survey requests for preparation and scheduling.

12. Material Testing

• QA Materials Testing will be provided by MCDOT

• QA Testing Plan

• Testing requests are to be made electronically through Enter Inspectors Name

• Two full working days advance notice is required for material testing requests for preparation and

scheduling.

Page 3 of 4 3/23/2017

• QC Testing is the responsibility of the Contractor

• QC Subcontractor

13. Contractor’s Submittals (Note: this is not a complete list)

• List of all Subcontractors

• List of Material Sources

• Preliminary Work Schedule

• Preliminary Traffic Control Plan

• Emergency Telephone Numbers

• Signing Authority Letter

• Name and Phone Number of the Certified Safety Professional

• SWPPP

• NOI

• Dust Control Permit

• Safety Plan

• OSHA 300 Logs

14. Construction Schedule – 00 Calendar Day Contract

• Notice To Proceed Date – Enter Date

• Projected Completion Date – Enter Date

• Work Hours – 0am – 0pm; Monday - Friday

• Weekly Meeting – to be determined later

• Contractor review project schedule

• Overtime and Weekend Work

• Contractor must advise MCDOT in advance of planned overtime and weekend work.

• Observed holidays -

15. Traffic Control

• Submit traffic control plans (TCP) electronically to Burt Neptune

• Keep copy of approved TCPs on project site during working hours

• Barricade Subcontractor –

• Lane restrictions and Flagger Operations

16. Progress Payments

• County accounting system requires processing of Monthly Progress Estimates by the third business day

of the month.

• Quantity cutoff date is the 20th of each month.

• Inspector prepares Monthly Progress Estimate and submits for processing by the 27th of each month.

• Quantities to be measured and agreed in field by Inspector and Superintendent daily.

17. Video Project –

• Contractor shall video the existing conditions of the project site and provide MCDOT with the video on

a flash drive at least 2-days prior to start of work.

18. Permits

• MCDOT Courtesy Permit.

• Dust Control – MCDOT received permit – E170669

• Notice of Intent (NOI) – MCDOT received waiver – AZG-2013001

Page 4 of 4 3/23/2017

19. Safety and Health

• Be aware of surroundings at all times.

• Contractor to follow safety plan on file with MCDOT

• All personnel on project site shall wear PPE

• Port-a-John required for jobsite

• Keep area cleaned daily

• Contractor Safety and Tailgate Meetings

• Invite Inspector to Meetings

20. Lesson Learned

• CM will email to all project participants the Lessons Learned document to fill out and return to him

after the construction phase is complete.

21. Open Discussion

PROJECT:

XXXX PROJECT NO: TT0XXX

CONSTRUCTION PHASE

WEEKLY AGENDA NO: XX

Meeting Location: Project Number: TT0XXX

Meeting Date: Meeting Subject: Progress

Contract Time: Calander Days NTP Date: End Date:Days Used: 0 #### Days Remaining: 0 ##### as of Accepted Delay Day(s): 0

1/0/00

Milestone Target

Start

Actual

Start

Target

Complete

Actual

Complete

Subcontractors

Subcontractor: Approval Start Comments

Item Description Status Due by Action

By A. 1.

SIGN IN / INTRODUCTIONS

See sign in sheet

B. CONSTRUCTION PROGRESS

1.

C. SCHEDULE – THREE WEEK LOOK AHEAD

1.

D. SAFETY & TRAFFIC CONTROL

1. 2.

Safety – All PPE must be worn while on project.

This week’s topic –

3.

Traffic Control –

E. 1.

REQUESTS FOR INFORMATION

See Attached Log.

F. SUBMITTALS

1. Submittal Log – See Attached Log.

Weekly Meeting Agenda #XX Page 2

Item Description Status Due by Action

By

G.

1.

CHANGE ORDERS

H. SURVEY

1.

I. COORDINATION (Contractors, Utilities, Other Agencies and Permits)

1.

Utility:

2.

Permits / ROW:

3

4..

Environmental / SWPPP:

IGA: (if applicable)

J. QUALITY CONTROL / QUALITY ASSURANCE

1.

CERTS – Reminder to send certifications of compliance as the material comes in.

Buy America (if applicable)

2. QC and QA Needs –

K. OUTSTANDING ACTION ITEMS

1.

L. COMMUNITY RELATIONS

1.

M. OFFICE

1.

2.

3

4..

Payments

Prompt Payment: (if applicable)

Payrolls: (if applicable)

Sub-contracts

N. 1.

PARTNERING/LESSONS LEARNED

Lessons Learned:

O. GENERAL COMMENTS

1.

MCDOT Representative: _____________________ Contractor: _______________________

Date: _________________________________ Date: ____________________________

Reporting Period From To

Project Name

Project Number Contract Number

Contractor Contract Amount

NTP Days Completed

Actual Start Date Elapsed Time

Contracted Days Work Completed

Earned To Date $0.00

Issues or Conflicts This Reporting Period

Anticipated Work For Next Reporting Period

Budget Status or Conflicts

Comments

Progress This Period:

#VALUE!

Construction Weekly Summary Report

xxx

TTxxx 20xx-xxx

#VALUE! #DIV/0!

Approved for

Payment $0.00

xxx

$0.00

Completion Date

Approved Change

Orders $0.00

xxx

xxx #VALUE!

#VALUE!

Revised Contract $0.00

P.E. # Paid Earned

1

2

3

4

5

6

7

8

9

10

Total Paid $0.00 $0.00

C.O. #

Extra Days

Approved Value

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Total Paid 0 $0.00

Pay Estimates and Change Orders Approved for Payment

Description of Change Order

Project Name

Project Number Contract Number

Contractor Contract Amount

NTP

Actual Start Date

Contracted Days

Construction Weekly Summary Report

xxx

TTxxx 20xx-xxx

xxx

xxx

xxx

xxx


Daily Diary

Daily_Diary_Rev.10/8/2018 Page 1 of 2

Report No:

Project Name:

Project No. Contract No. Federal Aid No TRACS No. Day of Week Date

Tuesday 10/20/2020 Prime Contractor Weather Temp. Range F° Wind

Work Performed / Inspections

Traffic Control

Survey

Materials


Daily Diary

Daily_Diary_Rev.10/8/2018 Page 2 of 2

Daily Quantities

Item No. & Description Location Unit Completed Qty

Labor and Equipment

Prime Contractor

Labor Classification Equipment

Work Description Labor / Equipment Classification Name Hrs.

Equipment No/License

Make & Model Hrs. Stand

By Hrs.

Rental

Labor and Equipment

Subcontractor





By Hrs.

Rental

Labor and Equipment

Subcontractor





By Hrs.

Rental

10/20/2020 Inspector Print Name Inspector Signature Date

Date Hours Notes

1/0/1900 0.00

Total Hours 0.00


Project No/Name:

OFF-DUTY UNIFORMED OFFICERS -SUMMARY

MARICOPA COUNTY DEPARTMENT OF TRANSPORTATION

UNIFORMED OFF DUTY OFFICER DAILY REPORT

PROJECT NAME:

PROJECT NO: DATE:

MCDOT REPRESENTATIVE:

CONTRACTOR REPRESENTATIVE:

AGENCY START TIME STOP TIME HOURS VEHICLE No.

Total Hours 0

CONTRACTOR REPRESENTATIVE SIGNATURE AND DATE

COMMENTS

MCDOT REPRESENTATIVE SIGNATURE AND DATE

WORK PERFROMED

OFFICER NAME (Print)

Submittal

No.

Description Date

Submitted

Date to

Reviewer

Returned

from

Reviewer

Forwarded

to

Contractor

Status

SUBMITTAL LOGEnter Project Name

MCDOT Project No. TT0xxx

1

RFI No. Page Reference Description Date

Submitted

Date to

Reviewer

Returned

from

Reviewer

Forwarded

to

Contractor

RFI LOGEnter Project Name

MCDOT Project No. TT0xxx

1

MATERIAL CERTIFICATION CHECKLIST AND/OR REJECTION NOTIFICATION

***DO NOT PAY FOR AN ITEM THAT THE MATERIAL CERT HAS NOT PASSED**

Date:

Project Name:

Project Number(s):

Material Cert No / Id (assign a #1,2,3 / log same)

Material Cert Name / Description:

Bid Item Reference:

Material Certifications Requirements 1. Project Name.

2. MCDOT Project Number.

3. Federal Project Number.

4. ADOT Tracs Number (if applicable).

5. The current name, address, and phone number of the manufacturer or supplier of the material.

6. Description of the material supplied.

7. Quantity of material represented by the certificate.

8. Means of material identification, such as label, lot number, or marking.

9. A Statement that the material complies in all respects with the requirements of the cited specifications.

10. Buy America Statement.

11. Authorization Statement: A Statement that the individual signing has the legal authority to bind the manufactureror the supplier of the material.

12. The name, title, signature, and date of signature of the signing-responsible individual.

Approved Rejected Notes / Comments if Applicable

#1

#2

#3

#4

#5

#6

#7

#8

#9

#10

#11

#12

Rejected – Return to Contractor – Please Revised and Resubmit

Approved (Log, File, do not return to Contractor)

Signature: Date:

Appendix F.14.3 Page 1

PROJECT NO.:

CONTRACTOR: TRACS NO: If applicable

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Bid Item No. Description

MARICOPA COUNTY DEPARTMENT OF TRANSPORTATION

MATERIALS CERTIFICATE LOG

DESCRIPTION / IDENTIFICATION OF MATERIAL

PROJECT NAME:

COMMENTS

CHECKLIST

TYPE OF CERT

REQ'D

DATE CERT

REC'D

DA

TE

MA

TER

IAL

CH

ECK

ED

AG

AIN

ST C

ERT.

Ce

rt A

cce

pta

ble

(Y

/N)

INSPECTOR

Mat

eri

al S

amp

led

(Y

/ N

)

Heat #, Lot #

Resident Engineer:As of 12/1/2020 1 of 7

Maricopa County Department of Transportation Permitting-Construction-Inspection

Punch List

Project: Project No:

Contractor: Inspector: Initial:

Item No.

Location (Road, Station, Offset) Description Origination

Date Contractor Notified

Date Date Completed

Inspectors Initial

Completed By: Signature: Date:

Reviewed By: Signature: Date:

PROJECT: DATE:

OWNER: Maricopa County Department of Transportation PROJECT NO:

DESCRIPTION OF WORK PERFORMED:

QUANTITY: 1

EQUIPMENT: (Blue Book HERR, ADOT 109)

INVOICE #: DESCRIPTION STAND BY HOURS RATE TOTAL

-$

-$

-$

-$

-$

-$

EQUIPMENT SUBTOTAL -$

LABOR:

INVOICE #: DESCRIPTION STANDBY HOURS RATE TOTAL

-$

-$

-$

-$

-$

-$

LABOR SUBTOTAL -$

MATERIAL:

INVOICE #: DESCRIPTION QUANTITY UNIT PRICE TOTAL

-$

-$

-$

-$

MATERIAL SUBTOTAL -$

SUBCONTRACTOR:

INVOICE #: SUBCONTRACTOR QUANTITY UNIT PRICE TOTAL

-$

-$

-$

-$

SUBS SUBTOTAL -$

SUMMARY

EQUIPMENT SUBTOTAL (ADOT 109 HERR includes 15% OHP) -------------------------------------------------- $0.00

TOTAL EQUIPMENT --------------------------------------------------------------------------------------------------------------- $0.00

LABOR SUBTOTAL ---------------------------------------------------------------------------------------------------------------- $0.00

50.00% LABOR BURDEN (ADOT 109) …….……………………………………………………………… $0.00

15.00% MARK UP ON LABOR (<$50,000)…………………………………………………… $0.00

12.00% MARK UP ON LABOR ($50,000 to $100,000)……………………………………… $0.00

10.00% MARK UP ON LABOR (> $100,000)………………………………………………… $0.00

TOTAL LABOR….………………………………………………………………………………………. $0.00

MATERIAL SUBTOTAL…………………………………………………………………………………. $0.00

15.00% MARK UP ON MATERIAL……………………………………………………………. $0.00

TOTAL MATERIALS…….………………………………………………………………………………. $0.00

SUBCONTRACTOR SUBTOTAL………………………………………………………………………. $0.00

10.00% MARK UP ON SUBCONTRACTOR - 10% or $300 (<$10,000)……………….

5.00% MARK UP ON SUBCONTRACTOR - (>$10,000).……….…………………………. $0.00

TOTAL SUBCONTRACTOR….….………………………………………………………………………. $0.00

SUBTOTAL $0.00

0.00% SALES TAX (enter actual rate)….…….…………………………………………………………………………………………. $0.00

0.00% BOND (enter actual rate)............................................................................................................................................... $0.00

TOTAL COST……………………………………….. $0.00

UNIT COST………………………………………….. $0.00

CONTRACTORACTUAL COST WORK (Per MAG 109.5)

Submit Completed Form To: (email)

SUBCONTRACTOR

ADDRESS

CITY, STATE, ZIP

TELEPHONE NO.

EMAIL ADDRESS (REQUIRED) $

CONTACT NAME (PRINTED) $

LABOR COMPLIANCE NAME

LABOR COMPLIANCE EMAIL

SUBCONTRACTOR R.O.C. NO.

SUBCONTRACTOR FED EIN NO.

LOWER TIER TO:

DBE: YES Date

$

$

$

$

$

$

$

CERTIFICATION:

The Prime Contractor and Subcontractor certifies the following:

A) The Subcontractor has received applicable Documents No. 2 through 15 identified below per Special Provisions.

B) The Prime Contractor and Subcontractor hereby transmit executed contract documents (numbers 1 through 13) to MCDOT for Subcontractor approval.

MCDOT approval is required prior to the start of Subcontractor's work.

C) DBE Subcontract documents shall be submitted at the Pre-Construction Conference per Special Provisions.

1. Subcontract Agreement containing the above Bid Items of Work

2. Standard Federal EEO, Executive Order 11246 Revised 04-15-81 (Federal Aid and Non FA projects)

3. Affirmative Action to Ensure Equal Employment Opportunity (Executive Order 11246), April 15, 1981 (Fed Aid and Non FA)

4. FHWA 1273 Rev.5-12 (Federal Aid Projects only)

5. EEO Compliance Reports, August 24, 2016 (Federal Aid Projects only)

6. Certification of Nonsegregated Facilities, September 29, 1975 (Federal Aid Projects Only)

7. DBE Provisions: with DBE Goal-LPA EPRISE 7/01/2017 or without DBE Goal-LPA EPRISE No Goal 09/19/16 (Federal Aid Projects Only)

8. MCDOT Title VI Assurances, Appendix A through Appendix E (Fed Aid and Non FA)

9. Exhibit 3A - Prompt Pay and Payment Reporting Provisions (Federal Aid Projects only)

10. Exhibit 16 - Labor Compliance and Payroll

11. Exhibit 31 - Section 106 of ADOT 2008 Standard Specifications - CONTROL OF MATERIALS with Cargo Preference Act

12. Exhibit 32 - Section 109 of Maricopa Association of Governments - Measurements and Payments

13. Wage Determination Decision # __________________ Mod # _______ (Federal Aid Projects only) As per special provisions for above referenced project

According to the appropriate Contract Provisions, %

has approved this date

$

Yes NoSubcontract in Project File:

Committed DBE

Committed DBE Subcontract and Affidavit Amount Match

Revised 01/2021

MCDOT PROJECT NO.

PRIME CONTRACTOR

FEDERAL NO./ADOT NO.

SUBCONTRACTED BID ITEMS No.'s

DO NOT FAX / DO NOT ALTER

SUBCONTRACTOR REQUEST FORM (SRF)

(documentation may be required)

ESTIMATED SUBCONTRACT AMOUNT

SUBCONTRACTOR AZ UTRACS NO.

PRIME AZ UTRACS NO.

TELEPHONE NO.

PRIME CONTRACT AMOUNT

Signature

SUBCONTRACTED NON-PAY ITEMS

(Provide Description of Work)

I CERTIFY THAT I AM A BONA FIDE TRUCK OWNER/OPERATOR

Authorized Subcontractor Signature

Date

Percent Subcontracted to date:

Total Prime Subcontracted to date:

FOR MCDOT USE ONLY

Chief Construction Engineer

Authorized Lower Tier Signature Authorized Prime Contractor Signature

Branch Copy File No. ______

MCDOT has implemented a subcontractor approval process which will ensure compliance.

It is MCDOT’s responsibility to ensure that prime contractors employ subcontractors in accordance with various Federal and State regulations.

*Attach additional SRF Form(s) if more bid items are needed

Non-Committed DBE

the Chief Construction Engineer

the subletting of the work items described above.

Title Date Title Date Title Date

(Check box and provide dollar amount for Joint / Partial Items)

CONSTRUCTION MARICOPA COUNTY DEPARTMENT OF TRANSPORTATION PERMITTING CONSTRUCTION & INSPECTIONS DIVISION

Draft 3 MCDOT 1.18.2019

SUBCONTRACTOR APPROVAL CHECKLIST

PROJECT NO: ADOT NO: DATE:

PROJECT NAME:

PRIME: SUB:

Task Description: __________________________________

(x)

1

ROC License – Verify on ROC Web Site - (www.azroc.gov) Current: Yes/No, Exp. Date: _____________ ROC License – print out – put with this packet ROC License Company Name matches name on SRF / Subcontract

2 SAM Website – Confirm registered. Required for projects awarded after 10-2014. (www.sam.gov, tab for search, search

records – enter company name - **sometimes, absolutely nothing shows, that's ok, if record shows, print out) 3 DBE AND AZ UTRACS No - Web Site (https://utracs.azdot.gov)

4 VERIFY: a) "Search DBE Directory" b) Type in Firm Name c) if SRF states Sub is DBE - click/mark the "DBE" box, c) "Search" d) name appears at bottom, click on "Profile", e) Print the page(s)

5 AZ UTRACS NO. CONFIRMATION (verify no. on print out to SRF) 5-digit no: ____ ____ ____ ____ ____

6 Is this a QA Subcontractor (look at bid items): If yes: Verify ADOT approved List (http://www.azdot.gov/docs/default-source/materials-group/directory-of-approved-materials-testing-laboratories.pdf?sfvrsn=4)

7 Review - Verify SRF Documentation for Accuracy EXCLUSIONS are an important component to review.

Project Name Project Number (MCDOT, Fed, ADOT #s) Prime Contractor Info: name/address/telephone Subcontractor Info: name/address/tele/contact name: _____ email________ Check w/DBE Profile _____ Subcontract Dollar Amount $__________________ Date Subcontract Executed: __________________ Bid Items List – Match Bid Schedule (Bid Item No & Bid Description matches bid word for word)

8 DBE Box Marked: NO_______ (#9 items below not required) YES_____ (complete #9 below)

9

DBE: Bid Items on Form must have dollar amounts included DBE: Hard Copy & Electronic Subcontract received DBE: DBE Assurances in Subcontract

10 EEO Clause included (attached if subcontract at $10,000 +)

11 Owner/Operator Truck Driver: NO______ (#10 items below not required) YES_____ (complete #10 below)

12 Project Wage Determination is correct? YES _____ NO _____

13 Owner/Operator Truck Driver Driver's License copy attached Owner/Operator Truck Driver Truck Registration attached

14 Owner/Operator Truck Driver MCDOT Form with equip info attached

15 Signatures: Prime Contractor / Subcontractor / Lower Tier (If applicable)

Rejected: Add to SRF Log – document Rejected/Pending (Provides current status) Email Prime Contractor and Project Team status

NOTE: If rejected, resubmitted, when approved, use the same form, mark up, make notes on it – this is a worksheet

Approved: SEND SRF NOTICE TO MCDOT – Include this statement in the email:

“ CEI request final approval and signature for the attached approved SRF from (name of sub firm).“

Add to SRF Log

Email Prime Contractor & Project Team - Attach pdf copy of SRF Log.

16. For File Record & Documentation: Print out SRF Log for File, action: SRF Log placed in file – Remove and Replace

a. Print out email of Reject/Approve status – save in file: Subcontractors Approved Notification

b. Hard Copy/Electronic signed & executed Subcontract: confirm the following are included within the subcontract

c.

Verify: ___ SRF-Contract Match (Dollars, Name, Bid Items) ___ Signatures ___ Dated correctly These Fed Docs must be included: ___ FHWA1273 ___ Cargo Pref Act ___ DB Wage Dec ___ Prompt Pay Provision ___ Title VI Assur ___ Title VI App A ___ Title VI App E ___ Records Retention Requirements ___ Immigration-Natl Act ___ EEO Compliance Report 10-20-15 ___ Ex Ord11246 7-1-78 ___ EEO Clause ___ EEO Not of Affirm Action 4-15-81

d. Scan / File: SRF / Checklist / Subcontract (including EEO, DBE, Truck Owner/Op Docs as applicable)

REVIEWED DATE: APPROVED DATE: REVIEWED BY: (print name and sign) SIGNATURE OF REVIEWER: _________________________

Printed: 12/1/2020

Project: ExampleContractor: Prime Start Work: Prime End Work:

Contract Amount: $1,000.00 Contract Time Began: Max 60%: $600.00

Date Approved Lower Tier To Subcontractor Start Date End Date Payrolls? DBE On DBE Affidavit? Subcontract Amount % of Contract Accum Amt Accum %

example NBC 200.00$ 20.00% 200.00$ 20.00%

example Upset 100.00$ 10.00% 300.00$ 30.00%

Appendix (F.12.1) A10.4 - SubcontractLog.xlsx

Created 7/19/16, JEE

Sign Salvage Manifest

Inspection Branch Job Location: ___________________________________2909 W. Durango St Phoenix, AZ 85009 Contractor Company: _______________________________ Date: ________________ Contractor Name: __________________________________ Inspector Name: _____________________________ Contractor Phone #: ________________________________

Permit and/or MCDOT Job #: ________________________________

All existing signs permanently removed by the contractor must be salvaged and returned to the Public Works Superintendent.

All salvaged signs shall be delivered to the Traffic Ops building at 2909 W. Durango St. Arrangements must be made for delivery by calling (602) 506‐8662.

Please have this manifest complete on delivery.

QTY DESCRIPTION

Other Comments:

Delivered by: __________________________________ Print: _____________________________________ Received by: ___________________________________ Print: _____________________________________ Date Received: _________________________________